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Class __Zi^ 
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GopyrigM?. 

COPYRIGHT DEPOSIT. 







A SERIES OF LECTURES ON 

SURGICAL NURSING & 
HOSPITAL TECHNIC 



By CONRADE A. HOWELL, M. D. 

MEMBER OF 

THE COLUMBUS ACADEMY OF MEDICINE 
THE OHIO STATE MEDICAL SOCIETY 
THE AMERICAN MEDICAL ASSOCIATION 
VISITING SURGEON TO GRANT HOSPITAL 

DELIVERED TO NURSES AT GRANT HOSPITAL, 

PROTESTANT HOSPITAL, COLUMBUS. 

STATE HOSPITAL 



WITH FIFTY- FIVE HALFTONE ENGRAVINGS 
THROUGHOUT THE TEXT, AND SIX PLATES 
ILLUSTRATING THE IDEAL OPERATING 
ROOM AND ITS ACCESSORY ROOMS 



of* 



Copyrighted, 1913, 
By C. A. HOWELL, M. D. 



THE STONEMAN PBESS 
COLUMBUS, OHIO 



£-&-o 



©CU330621 

fcot 



THIS VOLUME IS DEDICATED TO THE 
MEMORY OF MY PARENTS AS A SLIGHT 
TOKEN OF LOVE AND GRATITUDE 



PREFACE 

WHEN I was asked by the Superintendent of the Protestant Hospital 
Training School to deliver a series of lectures to the nurses on 
"Surgical Nursing," I did not appreciate the lack of literature on the 
subject; in fact, but for the many requests I had for copies of my lectures 
from different points of the state, I never would have realized how in- 
adequately the subject had been treated in the numerous books on nursing, 
It seems incredible, that progressive as the medical profession is, especially 
in the line of literature, the nurse's library should consist chiefly of such 
books as remind us of the commercial productions known as the "Family 
Doctor" and the "Medical Adviser." Every subject pertaining to nursing 
is crowded into one small volume ; obstetrics is given a few pages, dietetics 
is briefly discussed, the care of the infant is touched on, a few pages are 
devoted to materia medica, and so on through the category of the different 
departments of medicine, while surgical nursing is treated as though it were 
a minor subject. Feeling that the nurse should be treated with more con- 
sideration, I decided to place my lectures in book form in an endeavor to 
broaden the nurse's education by giving in a simple way the scientific basis 
of surgical nursing. Indeed, I was further induced to do so from the en- 
couragement which I received from out-of-town practitioners, who ex- 
pressed a desire for such a work as a guide in the after-treatment of sur- 
gical cases that were compelled by circumstances to undergo operations at 
their homes. 

I desire to express my indebtedness to the many authors whose names 
appear in the various bibliographies of this volume. Their wide experience as 
surgeons has been of great assistance to me in its preparation. 

To those of the profession whose names appear in the text I am under 
personal obligations because of their interest in the work. In some instances 
they have donated their valuable time in writing their suggestions on the 
various subjects on which they are authorities. 

To my colleagues Drs. J. J. Coons, J. D. Dunham, W. E. Lloyd, E. N. 
Ludwig. and \V. I. Jones, I especially desire to express my gratitude for the 
assistance I received at their hands. 

Many practical suggestions were made by Mrs. Harriet Fenzel, Superin- 
tendent of Nurses at the Protestant Hospital, and Miss Margaret Knierim, 



vi Preface 

Chief Operating-room Nurse at the same institution, for which I am pleased 
to make acknowledgment. 

The reading of the manuscript and revision of proofs were intrusted to my 
friend Mr. Paul C. Carty, Instructor of Printing in the Columbus Trade 
School. The difficulties of such an undertaking are only appreciated by 
those who have attempted a like task. I am deeply grateful to him for 
his services. 

There is no portion of this book in which my secretary Miss Lucy E. 
Dodds did not play an important part in its preparation. Many of the 
lectures were revised by her and reduced to their simplest terms, so as to 
omit the more technical expressions the profession is prone to use, and to 
bring the subject-matter easily within the range of the intelligent nurse. 
All references to authorities were left to her care. She also supervised the 
sequence of the lectures, besides aiding in the manuscript and in the details 
incident to the production of the illustrations. Without her aid the book 
would not have been produced, so that it is a pleasure to express my grati- 
tude, and give credit for the part she had in the work. 

With all the help and encouragement I received, and the efforts that were 
put forth, I feel very much like the one who wrote : "The very best of us 
leaves his tale half untold, his message imperfect ; but if we have been 
faithful, then because of us, some one who follows us, with a happier heart 
and in happier times, shall utter our message better and tell our tale more 
perfectly." 



CONTENTS 



LECTURE PAGE 

I Some Brief Historical Sketches .... 1 

Florence Nightingale — The International Red Cross Society — Clara 
Barton — The Pre-antiseptic Age — Louis Pasteur — Sir Joseph 
Lister. 

II Surgery, Surgical Nursing, Infection, Natural Re- 
sistance, Artificial Means to Increase Natural 
Resistance ......... 8 

Definition of Surgery — Definition of Surgical Nursing — Principles 
of Infection — Classification of Bacteria — Avenues by which Bac- 
teria Invade the Economy — The Lymphatic System — The Exit 
by which Bacteria Leave the Economy — Natural Resistance — 
Blood-counting — Table Indicating the Approximate Ratio Be- 
tween the Absolute and Differential Counts — Formation of an In- 
flammatory Action — Artificial Means of Assisting Natural Resist- 
ance — Artificial Hyperemia — Means for the Production of Hyper- 
emia — Vaccines — Wright's Hypothesis — Wright's Dictum. 

III Antiseptics, Disinfectants, Germicides, Deodorants, 
Sterilization ........ 19 

Definition of Germicide — Definition of Antiseptic — Definition of 
Deodorant — List of Antiseptics in Common Use — Approximate 
Ways of Obtaining Solutions by Apothecaries' Measure — Approxi- 
mate Ways of Obtaining Percentage Solutions — Approximate 
Table for Metric System — Dusting Powders — Abuses of Anti- 
septics and Germicides — Mechanical Antiseptics — The Sterilizing- 

room — Necessary Furniture — Stock Solutions — Drugs — Chemi- 
cals — -Hypodermic Tablets — Local Anesthetics — Gauze Prepara- 
tions — Accessories — Sterilization by Heat — Sterilization by 
Steam Under Pressure — Sterilization by Steam Without Pressure 
— By Boiling Water — By Dry Heat. 

IV Aseptic and Antiseptic Surgery .... 32 

Definition of Aseptic and Antiseptic Surgery — Common Examples 
of the Manner in Which the "Chain of Asepsis" is Broken by 
Careless Nursing and the Many Ways in Which Aseptic Wounds 
are Rendered Infected. 

VII 



viii Contents 

V Preparation and Sterilization of Gowns, Sponges, 
Dressings, and Other Articles Commonly Used in 
Surgery . . . . . . . .37 

Gauze — Gowns — Surgeon's Suit and Shoes — Caps — Face-masks 

— Nurse's Aprons — Gauze Sponges for Use in the Operating-room 

— Small or Wipe Sponges — Abdominal Sponges — The Large 
Abdominal Sponge or Towel — Preliminary Count and Record of 
Sponges — Dressings for Use in Operating-room — Plain Sterile 
Gauze Dressing or Fluffy Gauze — Cotton-gauze Dressings — Ab- 
dominal Outfit — Medicated Gauze — Sublimate Gauze — Iodoform 
Gauze — Tape or Gauze Packing — Oiled Silk — Rubber Dam — ■ 
Gutta-percha Tissue — Gloves — Care of Gloves After Being Used 

— Sterilization of Gloves — Manner of Adjusting Gloves — Talcum 
Powder — Towels — Operating-table Pads — Blankets — Rubber 
Sheets — Celiotomy Sheets — Ward Service Dressing Outfit — Liga- 
tures and Sutures — Definitions of Ligatures and Sutures — Classi- 
fication of Ligatures and Sutures — Catgut — Sterilization of Cat- 
gut — Kangaroo Tendon — Silk — Pagenstecher — Silkworm Gut — 
Horsehair — Wire — Drains — The Cigarette Drain — The Mi- 
kulicz Tampon — Rubber Drainage Tube — Roller Bandage — Gen- 
eral Rules for the Application of a Roller Bandage — A Scultetus 
Bandage — The "T" Bandage — Plaster-of-Paris Bandage — Rules 
for Applying — Method of Removal — Silicate-of-Soda Bandage — ■ 
Rules for Applying — Adhesive Plaster — Physiologic Saline or Nor- 
mal Salt Solution — Directions for Preparing — Field of Usefulness. 

VI Ward Service — History-record of the Patient . 61 

Necessary Articles of Furniture and Accessories to Successfully 
Carry Out the Scheme of Asepsis — Clinical Charts and Sickroom 
Memoranda — The Proper Manner of Keeping Clincial Charts and 
Sickroom Memoranda — History-record of the Patient and the 
Compilation of the Same — A Blank-form for History-records — 
Filing the History-records. 

VII Preparation and Sterilization of Surgeon's and 

Nurses' Hands ........ 72 

Basic Principles — Mechanical Cleansing — Different Methods of 
Hand Sterilization. 

VIII Preparation of Patient for Operation ... 75 

Classification of Operative Cases — The Manner of Giving a General 
Sponge Bath — Preliminary Duties and the Equipment of Ward 
Dressing Car with Such Articles as will be Necessary in the Prep- 
aration of the Patient — Nurse's Preparation — The Primary Prep- 
aration of the Field of Operation — Different Methods of Primary 
Preparation of the Field of Operation — The Soap Poultice — Ob- 
taining a Specimen of Urine — Modifications in the Preparation of 
Special Locations : Head, Mouth, Stomach, Face, Thorax, Rectum, 



Contents ix 

Vagina, Bladder, Hands, Feet — Further Necessary Preparation — 
Diet — A Practical Menu — Drinking Water — Cathartics — 
Hypnotics — Enemata — Patient's Attire for the Operating-room — 
Alkaloidal-narcotic Medication — Catheterization. 

IX Positions or Postures of the Patient Utilized in 

Surgery ......... 88 

Sims's Posture, also called the Semiprone — Dorsal Recumbent — 
Knee-chest Position — Dorsosacral or Lithotomy Posture — The 
Trendelenberg Position — The Hartley Position — The Fowler Posi- 
tion — Mechanical Ways of Obtaining the Fowler Position — Ad- 
vantages of the Author's Bed- frame — The Anatomic and Physio- 
logic Principles for the Use of the Fowler Position. 

X The Blood-vessels ....... 102 

The Division of the Vascular System — The Arteries — The Veins 

— The Capillaries — Definition of Anastomosis or Inosculation — 
Histology of the Blood-vessels — Process of Repair of Blood- 
vessels. 

XI Transfusion — Infusion ...... 105 

Definition of Transfusion — Indications for Transfusion — Acces- 
sories Necessary for Transfusion — Infusion as Applied to Surgery 

— General Effects of an Infusion — Intravenous Infusion — Infusion 
Reservoir — Infusion Needles — Choice of Location for Intravenous 
Infusion — Nurse's Duties — Modification in the Administration of 
an Intravenous Infusion — Proctoclysis, Enteroclysis, or Rectal In- 
fusion — Types of Apparatus for Proctoclysis — Requirements for 
a Proctoclysis Outfit — Administration of a Proctoclysis — Nurse's 
Duties — Wide Range of Application of Proctoclysis — Subcutaneous 
Infusion or Hypodermoclysis — Disadvantages of Hypodermoclysis — 
Choice of Location for Hypodermoclysis — Accessories Necessary 
for Hypodermoclysis — Method of Administration — Nurse's 
Duties — Intra-abdominal Infusion. 

XII Surgical Shock . . . . . . . .119 

Blood-pressure — Vasomotor Nerves — Causes of Shock — Trauma 

— Hemorrhage — Tissues Involved — Innervation of Part — Per- 
sonal Equation of the Patient — Psychic Causes — Theory of the 
Production of Shock — A Comparison Between Shock and Hem- 
orrhage — Treatment of Shock — Prevention of Further Shock — 
Transfusion — Solution of Adrenalin Chlorid — Intravenous Infu- 
sion — Mechanical Means — Rest — Nurse's Duties. 

XIII Hemorrhage ........ 126 

Definition of Hemorrhage — Classification — Arterial, Venous, Capil- 
lary or Parenchymatous — Concealed, Primary, and Secondary — 
Resume of the Physiology of the Blood — Pathology of Hemor- 
rhage — Symptoms of Hemorrhage — Treatment — Local Means 



x Contents 

Employed to Arrest the Flow — Posture — Pressure — Direct Pres- 
sure — Indirect Pressure — Heat — General Measures Utilized to 
Offset the Deleterious Effects on the Economy — Compensation for 
the Loss of Blood — Administration of Water by the Mouth — 
Rest — Conserving Body-temperature — Medicinal Agents — Alcohol 
and Other Stimulants Contraindicated while Hemorrhage is Oc- 
curring — Local Astringents — Monsel's Solution of Iron — Nurse's 
Duties. 

XIV Wounds, Contusions, and Abrasions .... 133 

Definition of Wound — Classification — Incised — Contused — Lacer- 
ated — Punctured or Stab Wound — Gunshot Wound — Open 
Surgical Wound — Repair of Wounds — Healing by the First In- 
tention, or Primary Union — Process of Repair — Healing by the 
Second Intention or Secondary Union, or Healing by Granulation — 
Process of Repair — Healing by the Third Intention — Recapitula- 
tion — General Consideration of Wounds — Pain — Ecchymosis — 
General and Local Resit — Cleanliness — Treatment of Wounds — 
Aseptic Incised Wounds — Principles Involved — Aseptic Open Surgi- 
cal Wounds — Principles Involved — Nurse's Duties — Change of 
Dressings — Aseptic Incised Wounds — Aseptic Open Wounds — 
Necessary Equipment — Steps of Technic — Nurse's Duties — Com- 
plications — Removal of Coaptating Stitches — Necessary Equip- 
ment — Steps of Technic — Infected Wounds — The Results of 
Wound Infection — Process of Healing Infected Wounds — Prin- 
ciples Involved — Drainage — Arrest Further Bacterial Invasion — 
Dry Dressings — Moist Dressings — Rest — Bier's Hyperemic 
Treatment. 

XV Fractures ......... 145 

Classification — Simple — Compound — Comminuted — Multiple — 
Impacted — Green-stick — Gunshot — Complicated — Causes of 
Fractures — Signs of Fractures — Loss of Function — Preternatural 
Mobility — Crepitus — Deformity — Radiograph — Repair of Frac- 
tures — Complications Following Fractures — Injuries of the Blood- 
vessels — Injuries of the Nerves — Delayed Union, Nonunion, 
Vicious Union — The Skin and Superficial Tissues — Decubitus (Bed- 
sore) — Treatment of Decubitus — Infection — Shock — Pneumonia — 
Treatment of Fractures — First Aid — Preparation of Patient in 
Fractures — Anesthesia in Fractures — Dressings Employed in Frac- 
tures — Splint-room — Modifications in Treatment of Fractures — 
Fracture Bed — After-treatment and Care of Fractures — Passive 
Motion. 

XVI Dislocations and Sprains ...... 162 

Articulation or Joint — Ligaments — The Synovial Membrane — 
Tendons — Classification of Dislocations — Causes of Dislocations — 
Exciting Causes — Predisposing Causes of Dislocations — Signs of 
Dislocations — Differentiation Between Fractures and Dislocations 
— Changes Occurring in the Joint after Dislocation (Pathology) — 



Contents 



XI 



Ankylosis — Treatment of Dislocations — First Aid — Treatment of 
Sprains — After-treatment of Dislocations and Sprains — Nurse's 
Duties. 



XVII Burns and Scalds ....... 

First-degree Burns — Symptoms and Course — Local Treatment — 
Constitutional Treatment — Second-degree Burns — Symptoms and 
Course — Local Treatment — Constitutional Treatment — Third-de- 
gree Burns — Symptoms and Course — Local Treatment — Constitu- 
tional Treatment — Causes of Death from Burns — Prognosis — 
Nurse's Duties — Electrical Burns — Lightning Stroke — Local 
Treatment — Constitutional Treatment. 



168 



XVIII Freezing and Frost-bites ...... 173 

Factors Governing the Effects of Cold on the Economy — Classifica- 
tion of Frost-bites and Freezing — Local Freezing — First Degree 
— Treatment — Second-degree Freezing — Treatment — Third- 
degree Freezing — Treatment — Chilblains — General Freezing — 
Treatment — Nurse's Duties. 

XIX The Operating-room and its Equipment . . 177 

Heating — Artificial Illumination — Water — Furniture — Care of 
the Operating-room — Surgeon's and Nurses' Dressing-rooms — 
Furniture Equipment of Each Room. 



XX Technic of the Operating-room .... 

Nurses' Preliminary Toilet — Preliminary Duties of the Non-sterile 
Nurse (Second Assistant) — Preliminary Duties of the First Assist- 
ant Nurse — Preliminary Duties of the Head Nurse — Final Duties 
of the Non-sterile Nurse — Final Duties of the Head Nurse — Final 
Duties of the First Assistant Nurse — The Operation — Modifica- 
tions of Technic for Special Locations — Operations on Head — 
Operations on Neck — Operations on Liver, Gall-bladder, and 
Hepatic Ducts — Operations on Kidney — Operations on Vagina — 
General Remarks. 



185 



XXI The Emergency Operating-room .... 199 

Emergency Operating-room Equipment — Maintaining the Equip- 
ment and Efficiency — Emergency Operating-room Technic — Duties 
of Second Assistant, or Non-sterile Nurse — Duties of Head Nurse 
— Duties of First Assistant Nurse — The Emergency Patient — Im- 
mediate Complications — Vomiting — Shock and Hemorrhage — 
Room Assigned for Splints and other Artificial Supports. 

XXII Principles and Practice of Postoperative Nursing . 204 

Assignment of Nurse — Positions of Patient in Bed Immediately 
Following Operations — Preparation of the Fowler Position — Flat 
Recumbent Position — Head-down or Foot-elevated Position — 
Artificial Heat — Nausea and Vomiting — Pain — Pulse and Tern- 



xii Contents 

perature — Respiration — Water and Nourishment — Diet List — 
Liquid Food — Soft Food — Special Diets — Nutrient Enemata — 
Rectal Feeding — The Administration of Nutrient Enemata — 
Nurse's Duties — Bladder — Catheterization — Urine — Bowels — 
Cathartics — Operative Wound, Dressings and Sutures — Necessary 
Equipment for the Removal of Sutures — Steps of Technic — Pa- 
tient's Toilet — Period of Confinement to Bed. 

XXIII Some Postoperative Complications .... 224 

Tympanites — Causes — Symptoms — Treatment — Nurse's Duties — 
Infection of Operative Wound — Symptoms — Causes — Treatment 

— Nurse's Duties — General Remarks on the Peritoneum — Peritoni- 
tis — Causes — Symptoms — Prophylaxis — Treatment — Septic Peri- 
tonitis — Phlebitis — Causes — Symptoms — Final Results — Treat- 
ment — Thrombosis — Causes — Classification — Symptoms — Final 
Results — Treatment — Embolism — Causes of Emboli — Classifica- 
tion — Symptoms — Treatment — Septic Intoxication Incorrectly 
Termed Sapremia — Symptoms — The Final Results — Treatment — 
Septicemia — Symptoms — Treatment — Nurse's Duties — Pyemia — 
Causes — Symptoms — Treatment — Nurse's Duties — Pneumonia — 
Treatment — Acute Obstruction of the Bowel — Causes — Symptoms 

— Treatment — Nurse's Duties — External Fecal Fistula Following 
Celiotomies — Causes — Symptoms — Treatment — Erysipelas — 
Causes — Symptoms — Treatment — Nurse's Duties — Tetanus or 
Lockjaw — Symptoms — Chronic Tetanus — Prognosis — Treatment — 
Diet — General Measures. 

XXIV Major Surgery in Private Practice . ... . 250 

Nurse's Immediate Duties — Surgeon's Outfit — Duties of Nurse 
on Arrival at Home of Patient — Extemporized Operating-room 

— Preparation of the Room (when time will permit) — A List of 
Necessary Articles — Sterilization — Preparation of the Patient — 
Preparation of Patient's Bed — Nurse's Duties the Day of Operation 

— Final Preparation of Field of Operation — Nurse's Duties During 
Operation — Preparation of Temporary Operating-room (when time 
is limited.) 

XXV General Anesthesia — Anesthetics .... 260 
Introduction — Historical — Nitrous Oxid — Ether — Chloroform — 
The Field of Application of Anesthetics — Mixed Anesthesia — 
Local Anesthetics Employed Contemporaneously with General Anes- 
thetics — Local Anesthetics Commonly Used — Strength of Solution 

— Anesthetic Mixtures — Anesthetics Administered in Sequence — 
Preparation of Patient — The Anesthetizing-room — The Anesthetist 

— Statistics — Chloroform — Physical and Chemical Properties — 
The Effects Produced by Inhalation of Chloroform — The Cere- 
brospinal Nervous System — Heart and Circulatory System — The 
Respiratory System — The Blood — The Kidneys — The Liver — 
The Skin — Indications and Contraindications for the Use of 
Chloroform — The Administration of Chloroform — Chloroform- 



Contents xiit 

ether Anesthetic Slip — Preliminary Steps — Inhaler — The Chloro- 
form Container — The Inhalation — Signs of Normal Surgical Anes- 
thesia — Untoward Conditions — Accidents Occurring During 
Chloroform Anesthesia — Symptoms — Treatment — Artificial Res- 
piration — Sylvester's Method — Howard's Method — Ether — Physi- 
cal and Chemical Properties — Effects Produced by the Inhalation 
of Ether — Cerebro-spinal Nervous System — The Heart and Cir- 
culatory System — The Respiratory System — The Blood — The 
Kidneys — The Skin — The Eyes — Indications and Contraindica- 
tions for the Use of Ether — The Administration of Ether — The 
Open Method — The Inhaler — Ether Container — The Inhalation — 
The Semi or Partially Open Method — The Inhaler — The Inhala- 
tion — Signs of Normal Surgical Anesthesia — Untoward Conditions 
— Accidents Occurring During Ether Anesthesia — Nitrous Oxid — 
Physical and Chemical Properties — Physiologic Effects Produced by 
the Inhalation of Nitrous Oxid — The Blood — The Cerebro-spinal 
Nervous System — The Heart and Circulatory System — The 
Respiratory System — The Digestive and Urinary Systems — Indica- 
tions and Contraindications for Use of Nitrous Oxid-oxygen — Ad- 
ministration of Nitrous Oxid-oxygen — Nitrous Oxid-oxygen 
Anesthetic Slip — Preliminary Steps — The Apparatus — The In- 
halation — Signs of Normal Surgical Anesthesia — Untoward Con- 
ditions — Accidents Occurring During Administration of Nitrous 
Oxid-oxygen. 



LIST OF ILLUSTRATIONS 



PAGE 

1 Sterilizing-room 26 

2 Autoclave 29 

3 Container for Tape or Gauze Packing 43 

4 Test Tubes for Tape or Gauze Packing 44 

5 Method of Preservation of Gloves 45 

6 Manner of Adjusting Gloves 47 

7 Tube of Catgut 50 

8 Simple Retaining Abdominal Binder 56 

8a Flasks of Normal Saline Solution 59 

9 Water Sterilizer 62 

10 Steam Sterilizer for Basins and Pitchers 63 

11 Immersion Trough 64 

12 Steam Sterilizer for Instruments 69 

13 Surgical Nurse in Complete Uniform 73 

14 Ordinary Dressing Car .......... 76 

15 Kelly Pad 77 

16 Improper Method of Hypodermatic Medication 86 

16a Proper Method of Hypodermatic Medication .... 86 

17 Sims's Posture (side view) 88 

18 Sims's Posture (end view) 89 

19 Dorsal Recumbent Position (side view) 90 

20 Dorsal Recumbent Position (end view) 91 

21 Knee-chest Position (table flat) 92 

22 Knee-chest Position (shelf attachment used) . . . . . 93 

23 Dorsosacral or Lithotomy Posture Obtained by Usual Method . . 94 

24 Dorsosacral or Lithotomy Posture Obtained by Clover Crutch . . 95 

25 Trendelenberg Position 96 

26 Hartley Position (showing foot-leaf and head attachment of the table) 97 

27 Patient in Hartley Position 98 

28 Author's Bed-frame to Obtain the Fowler Position .... 99 

29 Patient in Author's Bed-frame . 10O 

30 Extemporized Way of Obtaining the Fowler Position . . . 101 

31 Infusion Bottle Equipped with Air Pressure 107 

32 Author's Infusion Reservoir 108 

33 Author's Proctoclysis Outfit ......... Ill 

XV 



xvi List of Illustrations 

PAGE 

34 Extemporized Proctoclysis Outfit ....... 113 

35 Proctoclysis Outfit in Position . 115 

36 Shock Bed 124 

37 Esmarch Tourniquet .......... 129 

38 Plaster-of-Paris Cast with Fenester ....... 155 

39 Buck's Extension Apparatus ......... 156 

40 Double-inclined Plane Splint 157 

41 Fracture Box ............ 158 

42 Cradle 159 

43 Floor-plan of Operating-room and Auxiliary Rooms .... 178 

44 Ordinary Sponge- and Dressing-table ' 179 

45 Instrument-stand ........... 180 

46 The Ideal Operating-room (double-page illustration) between pages 180 and 181'< 

47 Surgeon's Dressing-room 182 

48 Nurses' Dressing-room 183 

49 Celiotomy Sheet in Place 189 

50 Proper Manner of Threading Needles 190 

51 lllienthal elevator in position ........ 194 

52 Cunningham Elevator in Position 195 

53 Lithotomy Sheet 197 

54 Self-retaining Catheters 218 

55 Extemporized Operating-room (double-page illustration) between pages 256 

and 257 • 

56 Anesthetizing-room 265 

56a Method of Administering a Local Anesthetic 269 

57 Esmarch Inhaler 280 

.58 Chloroform Inhaler 281 

59 Showing Parts of Allis Inhaler 289 

59a Assembled Allis Inhaler 290 

60 Teter Apparatus for Administration of Nitrous Oxid-oxygen . . 302 
•61 Nitrous Oxid-oxygen Face Inhaler 304 



FOREWORD 

THE rapid progress made by surgery in the last few years makes it 
imperative for the advanced surgeon to call to his aid only such 
nurses as are qualified to meet modern demands. Of late there has been 
a great deal of discussion in regard to overtrained nurses, whatever that 
may mean, but I believe the surgeon who is keeping in the front ranks of 
his profession is not alarmed at the well-informed nurse, because the nurse 
whose training has been properly supervised knows her province and sphere. 
She has been disciplined to realize that it is not her place to make sugges- 
tions, but to obey orders, and to carry out her duties in the most approved 
manner. In fact the higher the degree of education the nurse receives, the 
more does she appreciate her position, and vice versa, the lower the grade 
of her educational attainments, the more importance does she assume. 
There should be no fear in overeducating any one, and especially is this 
true in work pertaining to the protection of life. I believe the time has 
passed when the trained nurse should be considered a machine to auto- 
matically carry out details. Looking at the subject from a higher-educa- 
tional standpoint, I am thoroughly convinced that the well-informed 
nurse is one of the greatest assets a surgeon can possess. 

I have taken the liberty of leaving the path so long trod in text-books 
pertaining to nursing and have endeavored to give the elementary principles 
of surgery so that the nurse can in an intelligent manner carry out the 
orders of her surgeon, and be more competent to protect her patient 
from the many disastrous results which follow in the wake of automatic 
nursing. For similar reasons I have also mentioned some of the numerous 
complications following operative procedures and emergency cases, to- 
gether with the usual treatment for such conditions. 

Throughout the volume I have suggested the proper methods of hospital 
technic, so as to give an adequate idea of the manner in which the surgical 
department of the hospital should be conducted, — which in many instances- 
is sadly neglected. I fully realize that deviations may be necessary, never- 
theless, the principles involved in my suggestions will form a practical basis 
which may be changed to suit the requirements of any particular institution. 
In contrast to the facilities offered by a hospital and the technic which is 
there utilized, I have added a chapter on "Major Surgery in Private Prac- 

XVII 



xviii Foreword 

tice," which I hope will be of interest to the nurse, besides giving her some 
conception of what her duties will be at the home of the patient. 

Criticisms may be offered that the lecture on "General Anesthesia and 
Anesthetics" is treated too technically, yet this is a subject which cannot 
be discussed intelligently without entering somewhat into technicalities. 
However, it is given with the hope that it will aid those nurses who desire 
to become expert anesthetists, and better enable them to take up the more 
extensive works on this subject. 

C. A. Howell. 

70 West First Avenue, Columbus, Ohio. 



LECTURE I 

SOME BRIEF HISTORICAL SKETCHES 

Florence Nightingale (1820-1910) 

Fragile, remote, a lady dwelt apart 
A lifetime's space from all the life of men; 
Then softly slept. And England's mother-heart 
Grew very tender as she saw again 
Sick lads at Scutari, who kissed the pale, 
Swift shadow of Saint Florence Nightingale. 

— John Pearson. 

A series of lectures to nurses would be incomplete if at the onset I 
did not mention the name of Florence Nightingale, the first trained nurse 
in the world, and the first to grasp the true meaning of the necessities for 
the trained nurse. If any of you have not read the story of this heroine's 
life I would admonish you to do so. The inspiration one gets from her 
noble character must leave its impression for good, especially on you who are 
endeavoring to follow in the line and vocation she instituted. 

Born of wealthy parents in Florence, Italy, in 1820, she was baptized for 
the city of her birth. Her father, William S. Nightingale, was the owner 
of two large English estates, one of which was Lea Hurst Derbyshire, where 
Miss Nightingale's childhood was spent. 

"There she early developed that intense love for every living, suffering 
thing, that grew with her growth, until it became the master passion of her 
life. She was intensely fond of animals, and even after her name had be- 
come illustrious, she wrote: 'A small pet animal is often an excellent com- 
panion for the sick, for long chronic cases especially.' " 

With wealth and education around her, Miss Nightingale soon absorbed 
that grace and refinement which seemed to play such an important part in 
her future career. History tells us how these characteristics continually 
bubbled through her nature at all times. It depicts her sympathy, her in- 
tense desire to aid the suffering, and her quiet, lovable, and affectionate 
nature. The study of nursing was her prevailing ambition. 

At the time I am relating, nursing was at such a low ebb, and was con- 
sidered such menial work, that when servants lost their positions and were 

(i) 



2 Florence Nightingale 

unable to obtain others, they applied for places as nurses in hospitals. Think 
of the immense chasm Miss Nightingale had to bridge to change public 
sentiment in England and cause it to look on the trained nurse as next in 
authority to the physician at the sick bed! Her task has been well done. 
She molded public feeling to such an extent that today the trained nurse is 
considered not only as a necessity, but as one who has given up her life ex- 
clusively to appease, quiet, and soothe the sick. She transformed the dirty, 
filthy, slovenly nurse of old to our present model of cleanliness. She 
changed the despised epithet of "nurse" of former days to the same name 
that carries with it now fidelity, love, and sympathy. 

Miss Nightingale's first active step toward nursing was at Pastor Flied- 
ner's Deaconess's Home at Kaiserworth, where she remained for some 
months. She next went to St. Vincent de Paul in Paris. On her return to 
England she reorganized a sanatorium in Harley Street, and was lost to the 
world for two or three years in her efforts to save this institution. Her work 
and long anxiety in this place broke down her health. 

In 1854 the Crimean War was at its climax. The English newspapers 
told true but heartrending descriptions of the suffering and maltreatment 
that was going on in its military hospitals, while hundreds of private letters 
from the front implored aid. 

W. H. Russel, "The Times" correspondent, in one of his letters, wrote: 
"The commonest accessories of the hospital are wanting, there is not the 
least attention paid to decency or cleanliness, the stench is appalling, the 
fetid air can hardly struggle out to taint the atmosphere save through the 
chinks in the walls and roofs, and for all I can observe these men die with- 
out the least effort being made to save them. Here they are just as they 
were laid gently down on the ground by the poor fellows, their comrades, 
who brought them from the camps with the greatest tenderness, but who 
were not allowed to remain with them. The sick appear to be attended by 
the sick, and the dying by the dying." 

Miss Nightingale was then recuperating her health after the years spent 
in reorganizing the Harley Street Sanatorium. The flower of England had 
lost its head as to what was best to be done, but Miss Nightingale at once 
conceived the idea of writing Lord Sydney Herbert, Minister of War, and 
offering her services. Strange as it may seem Lord Herbert wrote her 
on the same day, knowing her achievements as an organizer and nurse only 
too well, and requested her to take charge of the hospitals at the Crimea. 
In his letter he gave her absolute authority over all nurses, unlimited power 
to draw on the government for all supplies for the success of the operations, 
and assured her of the cooperation of the surgical staff, concluding the 



Florence Nightingale 3 

letter thus : "Your personal qualities, your knowledge, and your authority 
in administrative affairs all fit you for this position." 

This was on the fifteenth day of October, 1854; on the twenty-first of the 
same month Miss Nightingale, accompanied by thirty-four nurses, left for 
the field of action. 

Here was not a case where emotion had tempted this beautiful woman 
to forsake home comforts for the rough life of the battlefield; there was 
none of the hysteria, so common at such times, that excited her into this 
mood, but simply the innate love for suffering humanity, the intense desire 
to' help and alleviate pain, and to do as much good as possible with the 
education she had obtained in the different hospitals where she had visited. 

"From October 30, 1854, the heroine of the Crimean War was Florence 
Nightingale, and the heroine of that war will she be while the English 
tongue exists and English history is read." 

She transformed the miserable hospitals as described by Mr. Russel into 
places that were veritable solaces for the sick ; filth, unwholesome food, and 
negligence were supplanted by cleanliness, attention, and care. An invalids' 
kitchen was instituted, laundries established, and personal attention given 
to nursing. 

Such an impression did her character make that "The Times" corre- 
spondent wrote: "Wherever there is disease in its most dangerous form, 
and the hand of the spoiler distressingly nigh, there is that incomparable 
woman sure to be seen ; her benignant presence is an influence of good com- 
fort even amid the struggles of expiring nature. She is a ministering angel, 
without any exaggeration, in these hospitals, and as her slender form glides 
quietly along each corridor, every poor fellow's face softens with gratitude 
at the sight of her. When all the medical officers have retired for the night, 
and silence and darkness have settled down upon these miles of prostrate 
sick, she may be observed, alone, with a little lamp in her hand, making her 
solitary rounds. With the heart of a true woman and the manner of a 
lady, accomplished and refined beyond most of her sex, she combines a sur- 
prising calmness of judgment and promptitude and decision of character. 
The popular instinct was not mistaken, which, when she set out from Eng- 
land on her mission of mercy, hailed her as a heroine ; I trust that she may 
not earn her title to a higher, though sadder, appellation. No one who has 
observed her fragile figure and delicate health can avoid misgivings lest 
these should fail." Even Longfellow wrote the charming poem, "The Lady 
with the Lamp," while the statue of Florence Nightingale at St. Thomas's 
Hospital, England, testifies to the love the people had for this wonderful 
woman. 

A letter from a soldier tells of the love the men at the front had for her. 
It reads like this : "She would speak to one and another, and nod and smile 



4 The International Red Cross 

to many more ; but she could not do it to all, you know, for we lay there by 
the hundreds ; but we could kiss her shadow as it fell, and lay our heads on 
our pillows again, content." 

Can you conceive of anything more beautifully impressive than that? 
Can you gather any moral that we should try to cultivate after hearing 
these lines? Can you fully appreciate the longings of a patient for her 
nurse? The long hours of sickness and pain create in us a desire for love 
and affection, and who can give it better than the nurse ? There are so few 
of us who are true to our profession. 

In acknowledgment of Miss Nightingale's splendid work Her Majesty 
presented her with a "beautiful and costly decoration," and the nation gave 
her two hundred and forty thousand dollars as a recompense for what she 
had done. This, however, she refused to accept for herself, but used it to 
build the Nightingale Home — a home for nurses. 

This wonderful woman died August 13, 1910. Probably no crowned 
head could have had a more imposing furneral than our heroine, had she so 
desired, but true to her nature she especially requested the simplest form 
of services to be held. The universal expressions of sorrow and regret from 
every class and from every nation mark her as one of the most imposing 
characters of this century. 

I could delineate to a greater length on the achievements of this noble 
woman, but sufficient I hope has been said to instill within each of you a 
desire to read the several memorials that have been written about her; and 
I hope sufficient interest has been aroused to show you what a noble voca- 
tion nursing has become, how far reaching is its influence, and what obliga- 
tions you owe the profession you have chosen for your own. 

the international red cross society 

This society was founded in Geneva, Switzerland, in 1863, but the neces- 
sity for such an organization really had its inception in the mind of Florence 
Nightingale during the Crimean War. 

It was Henri Dunant, a Swiss, who really laid the foundation for the 
present concrete society, having witnessed the massacre at Mantua, Italy, in 
1859, when there lay sixteen thousand French, and twenty thousand 
Austrians, dead and wounded on the field of carnage. Recognizing how 
inadequate were the hospital facilities, he proposed to a philanthropic society 
at Geneva to establish a volunteer medical force to supplement the regular 
army surgeons during war. A general invitation was then sent out and 



The Pre-antiseptic Age 5 

fourteen countries were represented. Turkey, Greece, and Portugal, and the 
papal states were marked by their absence. America was not represented. 

"The delegates recommended that each government extend its sanction, 
authority, and protection to sanitary commissions and their relief corps, 
that in time of war the privilege of neutrality be extended to ambulances, 
military hospitals, officials and attaches of the medical service of the army, 
and to the inhabitants living in the theatre of war who should receive and 
care for the wounded in their houses, and that the universal insignia and 
flag should consist of a white flag or band with a red cross. This was 
adopted as a tribute of courtesy to Switzerland, the parent country of the 
idea, whose flag is a white cross on a red background. The United States 
was represented the following year ; its two delegates reported at the second 
meeting of the Red Cross, the success this country had with its sanitary 
commission at the opening of the Civil War. This testimony from the 
United States, setting forth the practicability of a movement similar to the 
Red Cross, was a splendid inspiration to the founders of the new 
organization." 

A similar society was founded in this country the year following the 
close of the Civil War known as the "American Association for the Relief 
of Miseries on the Battlefield." Associated in this movement, the name of 
Clara Barton (1821-1912) should be brought to your attention. She was a 
clerk in Washington when the hostilities between the North and South 
began, and entered the hospital service of her country. "Subsequently she 
gave her service in the Franco-Prussian War and at its close was decorated 
with the Gold Cross of Baden and the Iron Cross of Germany. It was 
through her efforts that the American Red Cross of today was organized in 
1881 ; she remained its president until 1904. The International Red Cross 
acts under the only universal conservation treaty in existence." All nations 
belong to it according to an agreement of 1906, its operations extending even 
to naval warfare. The Asiatics were the last to sign the agreement. Its 
labors are not limited now to warfare, but to all catastrophies, such as earth- 
quakes, mine disasters, fires, tidal waves, and epidemics. 

It is this society which is making such a fight against tuberculosis and 
which issues annually at Christmas time the Red Cross seals or stamps, the 
sale of which amounted to over three hundred and fifty thousand dollars 
the first two years. 

THE PRE-ANTISEPTIC AGE 

Wherever men are gathered or encamped in large numbers there epidemics 
occur, unless modern medicine steps in and by its marvelous sanitary 
methods prevents devastation of human life, — the Crimean War was a 
fearful example. Soldiers were killed in battle by tens of thousands, but 



6 Louis Pasteur — Sir Joseph Lister 

they were dying with various diseases by hundreds of thousands. This 
war was the last in which the old methods of treating wounds were used; 
it was the so-called pre-antiseptic age. Hospital gangrene from the most 
trivial injuries was more common than gunshot wounds, erysipelas could 
be seen devastating whole camps, and a pall seemed to rest on the greatest 
minds in surgery, — so beaten back and overcome by the lack of science that 
the stoutest-hearted and boldest surgeons were discomfited and discouraged, 
and their former vigorous enthusiasm was on the wane. 

LOUIS PASTEUR ( 1 822- 1 895) SIR JOSEPH LISTER (1827-I912) 

On the horizon there appeared Louis Pasteur, a French chemist, who in 
1858 announced that fermentation and putrefaction were due to micro- 
organisms or bacteria, which are minute vegetable organisms. This keynote 
was grasped by another, and the world was to see the turning point from 
slovenly and filthy surgery to one which has as its basis "surgical cleanli- 
ness." Picking up the lines or keynote left by Pasteur, Sir Joseph Lister in 
1865, working with undaunted courage and overcoming all difficulties, even 
at the criticism and ridicule of his brother surgeons, issued his "Germ 
Theory of Disease." 

The opposition that this theory met with and the epithets that were hurled 
at this author would have deterred anyone, save and except one like Sir 
Joseph Lister. Such eminent men as Lawson Taite, than whom there was 
never a greater surgeon, ridiculed his methods even to the time of his death, 
and men of like standing never lost a chance to jeer his theories. This year 
marked the birth of modern clinical surgery. 

Lister believed that microorganisms or bacteria entering into wounds 
caused inflammation and its sequela suppuration or pus, and that the atmos- 
pheric air was the vehicle or carrier by which germ life was transplanted 
into wounds. He began experimenting, having chiefly in mind two points, 
(1) the disinfection of the air around the field of operation, and (2) the 
keeping of the wound in such a state as to prevent the entrance of bacteria 
into the tissues. 

After experimenting with various drugs he decided that carbolic acid was 
the remedy par excellence. He therefore designed large steam atomizers 
that sprayed this irritating substance, not only through the operating-room 
to keep the air purified, but also a continuous spray was maintained over 
the hands of the operator, the instruments, and the field of operation, and 
it is even within the memory of the writer when such a technic was carried 
out. I well remember one of the first Cesarean sections that ever occurred 
in Ohio to my knowledge, when one was unable to see the surgeon across the 
room on account of the spray from one of these steam atomizers. No ridi- 



Sir Joseph Lister 7 

cule must be made of this crude technic; it became the corner-stone for our 
modern surgery, and gave excellent results as compared to the methods 
employed by the older surgeons. Compound fractures which had a mortal- 
ity of nearly eighty per cent, soon lost their fatality, hospital gangrene soon 
became amenable to treatment, and hospitals which formerly had been pest- 
houses and had to be closed for months at a time on account of the ravages 
of erysipelas and other contagious diseases, now became homes of refuge. 

Sir Joseph Lister fortunately was the son of a wealthy English wine 
merchant; the elder man was somewhat of a scientist, and this trait was 
greatly amplified in the younger Lister, who not only accomplished what 
I have already related, but went further and helped to develop the micro- 
scope ; in this way he carried on his research work and placed it on a basis 
above ridicule. He truly burned the barriers away, and blazed the path for 
future generations. 

Finally to him must be attributed the honor of having first used ab- 
sorbable animal tissue for ligatures and sutures. It would be impossible to 
estimate the value of this discovery to surgeons, as many of our most 
brilliant operations could not be accomplished without animal sutures. 
Lister therefore is one of the greatest of our patron saints. His name and 
what he has accomplished for mankind can never die, and it is but fitting 
that before entering on the subject of "Surgical Nursing," the names of 
Florence Nightingale, Louis Pasteur, and Sir Joseph Lister be brought to 
your notice, and the origin of the Red Cross, which forms the insignia of 
your profession, be mentioned. 

BIBLIOGRAPHY 

Great Men and Famous Women — Lizzie Allridge. 

The Red Cross Society — Frederick Haskins. 

The Encyclopedia Americana. 

Keen's Surgery — James G. Mumford, M. D. 

American Practice of Surgery — James E. Moore, M. D. 



LECTURE II 

SURGERY, SURGICAL NURSING, INFECTION, NATURAL 

RESISTANCE, ARTIFICIAL MEANS TO INCREASE 

NATURAL RESISTANCE 

Surgery is that branch of medicine which treats diseases by mechanical 
methods or operative procedures. 

Surgical Nursing is that art which the nurse uses in the care of surgical 
cases. 

Principles of Infection. — As the knowledge of this subject is one of the 
foundation principles on which modern surgery is based, I have chosen this 
as the first topic for discussion. In fact, so important is the knowledge of 
this subject, that it forms the keynote of the entire field of modern medicine. 

The historical facts I have related, as first suggested by Sir Joseph Lister, 
are as true today as when he first discovered them. His idea that the en- 
trance of germs into the tissues causes inflammation, is our present knowl- 
edge of what is known as infection. 

"When bacteria, sufficient in number or virulence to overcome the natural 
resisting powers of the tissues, have gained entrance in the economy, it is 
infected." — Jas. E. Moore, M. D. In other words, infection is the successful 
entrance and multiplication of bacteria in the economy. When the infection 
is limited to a small area it is known as a local infection, the symptoms of 
which are recognized as inflammation, heat, redness, swelling, pain, and 
suppuration or pus, — the last step in this process, — which is simply "the 
molecular death of the tissues in a state of solution!' When the infection 
has spread so that the blood-current has become contaminated it is termed 
general infection. (See lecture on "Some Postoperative Complications," 
sections "Septic Intoxication," "Septicemia," and "Pyemia.") 

After bacteria have gained a foothold in the economy they eliminate 
toxins, which are chemicals or poisons capable of producing a similar in- 
fection to the bacteria from which the toxins are obtained. So that by the 
term toxemia is understood blood-poisoning. Ptomains are the poisonous 
products eliminated from putrefactive bacteria only. 

Some of the More Common Bacteria. — There are numerous kinds of 
bacteria capable of producing infection, but it is not necessary to mention all 

(8) 



Classification of Infections 9 

the different varieties. Those which are met with most frequently are, (1) 
the streptococcus, (2) staphylococcus, (3) gonococcus, (4) the colon 
bacillus, (5) pneumococcus, (6) the tubercle bacillus, (7) tetanus bacillus, 
and to these may be added (8) the spirocheta pallida. The history, mor- 
phology, and other data concerning these you have gained in your study of 
bacteriology. 

A simple infection is one caused by a single variety of bacteria. By a 
mixed infection is inferred that two or more varieties of microorganisms 
are producing the pathologic condition, while a secondary infection is where 
the primary infection has been aggravated by the entrance of entirely differ- 
ent bacteria. 

Secondary infections are not always the result of carelessness, yet I think 
I am conservative in saying in a large majority of cases they are. Fre- 
quently one witnesses operations performed in the most aseptic manner, 
careful consideration given each detail, and then sees an equal amount of 
carelessness exhibited in the dressing the part receives from time to time. 
Hence I say careless methods are very often the gateways through which 
secondary infections occur. 

Avenues by which Bacteria Invade the Economy. — There are numerous 
portals through which bacteria may gain entrance, among which may be 
mentioned wounds or abrasions. Any break in the continuity of the body- 
surface invites the invasion of microorganisms. A wound may become in- 
fected from the following sources: (1) Dirt or infectious material on the 
instruments or any other means by which the wound was inflicted, (2) sim- 
ilar material on the wounded part, (3) infection on the hands of the attend- 
ants, (4) instruments or suture material not thoroughly sterilized, (5) sep- 
tic dressings. 

Infection may take place without the presence of a wound or abrasion. 
Under the outer layer of the skin lives the staphylococcus epidermis albus, 
in which locality this microorganism seems to remain latent, or domesticated. 
When a part of the body-surface has received a trauma or blow insufficient 
to produce an abrasion or wound, but yet of such severity as to reduce the 
resisting power of the part, these microorganisms gain a foothold and an 
infection ensues. Again the resisting power of a part may be reduced by 
anything that interferes with its circulation, as an example, excessive ten- 
sion of sutures that coaptate the edges of a wound. Bacteria may gain 
entrance through the skin by penetrating the shaft of a hair-follicle, in this 
way producing a severe inflammatory action, such as is seen in carbuncles, 
boils, etc. A few of the most virulent forms of microorganisms are capable 
of passing directly through the mucous membrane whose surface continuity 
has not been broken. Because of the high resisting power of this tissue, 



10 Lymphatic System 

and the fact that the bacteria have to be of the most infectious type, this 
form of invasion is not a frequent occurrence. Another common way for 
infection to occur is through the uterine canal (especially in connection 
with abortions) or by the use of dirty instruments introduced within its 
cavity. Infection following surgical operations may develop from any, or 
all of the sources I have mentioned. The respiratory tract and the gastro- 
intestinal canal are other channels by which bacteria enter the economy. 

The question may arise as to the manner in which infection spreads 
through the system after bacteria have gained entrance. If the natural re- 
sisting powers of the economy are not great enough to overcome the invad- 
ing bacteria, the absorbents, known as the lymphatics, absorb these micro- 
organisms or their toxins, or both, and eventually empty this septic material 
into the blood. Occasionally, however, an infection is so rapid in its 
progress and so devastating from the very onset, that one is forced to con- 
clude that microorganisms enter the capillaries directly, and thus gain en- 
trance into the blood-current; in other words, short-circuit the route, but 
this latter is not the general mode of invasion. 

The Lymphatic System. — The lymphatics or absorbents of our bodies are 
composed of (1) spaces without any definite limiting wall, situated chiefly 
among the capillary blood-vessels ; from this origin begin (2) lymph-vessels 
of various sizes which communicate freely with each other and possess nu- 
merous valves to prevent "back flow" of their contents. During the course 
of these vessels glands are seen ; the vessel entering such a gland breaks up 
into numerous smaller vessels, and again unites to form a trunk when 
leaving the gland. (3) Glands. These, as I have mentioned, are found in 
the course of the larger vessels ; their function being to purify the contents 
of the vessel. In other words they are purification plants, or filtration de- 
pots. These numerous vessels converge into two trunks, the thoracic and 
right lymphatic ducts, which pour their contents into the left and right sub- 
clavian veins respectively. Thus a direct communication is established be- 
tween the lymphatic and vascular systems. The contents of these vessels, 
whether it be normal lymph or infectious material, is propelled through the 
lymphatic system by muscular movement. This composite stream is known 
as the lymphatic-current. 

I desire to indelibly impress on your minds the fact, that if a local- 
infected area is so immobilized that muscular movement of the part supplied 
to the surrounding lymph-vessels is prohibited, the lymph-current is checked, 
and a general infection averted in a large majority of cases. This is the 
foundation principle in the treatment of all infections. 

The Exit by which Bacteria Leave the Economy. — It has not been clearly 
demonstrated how bacteria are excreted from the body, but clinical expe- 



Natural Resistance — Blood-counting 11 

rience indicates that the kidneys are the chief organs concerned in their 
elimination. Such an important factor should ever be borne in mind in the 
preparation and after-treatment of all surgical cases. 

Natural Resistance. — The next subject I desire to call your attention to 
is the steps Nature takes to protect herself. Studies along the lines of "nat- 
ural resistance/' "protective agencies," or "body-resistance," which the econ- 
omy exerts in self-defense, have only thrown a meager light on this impor- 
tant subject. I say the knowledge is limited, but the little that is known I 
desire to explain. 

In your study of physiology you have learned the constituents of the 
blood and the respective functions of each. You will recall how the white 
blood-corpuscles or leukocytes act the dual role of soldiers and scavengers ; 
how they devour and digest bacteria and necrotic tissue produced by an 
inflammatory action; how they make away with putrefactive conditions, 
when present, and blood-clots which are left from surgical operations or 
hemorrhages. This function is termed phagocytosis. 

Another important function attributed to the leukocytes is their power of 
eliminating chemical products, or alexins, as they are termed, which assist 
in the destruction of pathogenic microorganisms. These important leuko- 
cytes, however, are impotent to cope with bacteria and their toxins by them- 
selves ; they need ammunition just as soldiers in the field do for an attack 
on an invading army. This is supplied in the blood-serum, which possesses 
(among other protective agencies) opsonins, which acting chemically on the 
invading microorganisms prepare them for destruction by the phagocytes (a 
variety of leukocytes). A deficiency of this serum, or the lack of some of 
its constituents, will prevent these little discs from functionating to their 
normal capacity; therefore, these two elements of the blood (leukocytes and 
blood-serum) depend the one on the other for their ultimate success as pro- 
tective agents. 

In making a comparison between the function of the blood-corpuscles and 
soldiers, I have in no way exaggerated the picture. Within a normal body 
there are from eight to ten thousand white blood-cells in every c.mm. of 
blood which constitute its standing army. In most infectious diseases this 
number is increased, so that reinforcements are called forth to an extent 
where every c.mm. may contain one hundred thousand of these cells. If 
the invading army is powerful, that is to say, if the infection is virulent, 
Nature calls on her resources proportionately for protection. 

Blood-counting. — The estimation of the number of red and white blood- 
corpuscles is termed blood-counting. An increase of the normal number of 
white blood-cells is termed leukocytosis, a decrease of the same, leuko- 
penia. When a blood-count is made and the number of white blood- 



12 Value of Blood-counting 

corpuscles stated, this is called the absolute count, and indicates the amount 
of self-defense or resisting power the patient possesses. By the term differ- 
ential, or relative count, is understood the number of each variety of leuko- 
cytes found in the absolute count. For all practical purposes it is only 
necessary to call your attention to that variety termed "polynuclear neu- 
trophiles," or in hospital parlance "polynuclears," which are found in the 
ratio of 75 per cent, of the leukocytes in normal blood of the adult. The 
higher the per cent, of polynuclears, the more severe is the infection. To be 
concise, the higher the absolute count, the greater is the patient's resisting 
power; the higher the per cent, of polynuclears, the graver is the infection. 
A blood-count to be valuable should be made repeatedly. Ah increasing 
absolute count indicates an increasing infection, and a proportionate body- 
resistance. A decreasing absolute count, with the ratio of polynuclears not 
decreasing, indicates the patient's resisting power is waning. Thus knowing 
the amount of resisting power as shown by the absolute count, and the viru- 
lence of the infection as indicated by the differential count, the surgeon is 
in a position to give a definite prognosis, or decide whether an operation is 
advisable in the presence of an acute infection. 

TABLE INDICATING AN APPROXIMATE RATIO BETWEEN THE ABSOLUTE AND 

DIFFERENTIAL COUNTS. 

Compiled by J. J. Coons, M. D., Columbus, Ohio. 

Absolute count Differential count 

or or 

Amount of resistance. Amount of virulence. 

74000 96.6 

73000 96.56 

72000 96.52 

71000 96.46 

70000 96.43 

69000 96.37 

68000 96.33 

67000 96.27 

66000 96.21 

65000 96.15 

64000 96.1 

63000 96. 

62000 95.96 

61000 95.9 

60000 95.83 

59000 95.75 

58000 95.7 

57000 95.6 



Value of Blood-counting 13 



Absolute count 

or 

Amount of resistance. 

56000 


Differential count 

or 

Amount of virulence 

95.5 


55000 


95.4 


54000 


95.35 


53000 


95.28 


52000 


95.2 


51000 


95.1 


50000 


95. 


49000 


94.9 


48000 


94.8 


47000 


94.7 


46000 


94.5 


45000 


94.4 


44000 


94.3 


43000 


94.15 


42000 


94. 


41000 


93.9 


40000 


93.8 


39000 


93.6 


38000 


93.4 


37000 


93.2 


36000 


93. 


35000 


92.8 


34000 


92 6 


33000 


92.4 


32000 


92.1 


31000 


91.9 


30000 


91.6 


29000 


91.3 


28000 


91. 


27000 


90.7 


26000 


90.3 


25000 


90. 


24000 


89.5 


23000 


89.1 


22000 


88.6 


21000 


88. 


20000 


87.5 


19000 


87. 


18000 


86 . 1 


17000 


85.2 


16000 


84.3 


15000 


83 . 3 


14000 . 


82.1 


13000 


80. 


12000 


79.1 


11000 


77.2 


10000 


75. 



14 Inflammatory Action 

There are certain localities in the economy where the resisting power of 
the body seems to be greater than others, and fortunately it is so ; because 
these are localities where artificial means of sterilization cannot be used, 
such as the rectum, vagina, mouth, nose, etc. — as a general proposition, the 
mucous membranes lining the orifices of the body. These openings are sub- 
ject all the time to infection from numerous bacteria, but become more or 
less immune. 

There are some tissues that seem very susceptible to infection, viz., the 
medullary substance of the long bones, fat, and synovial membrane. This 
should be borne in mind, and the most rigid precaution taken when opera- 
tions are made involving these tissues. 

Formation of an Inflammatory Action. — After bacteria have entered a 
part of the body and eliminated their toxins, an inflammatory action is 
aroused. The bacteria and toxins cause a paralysis of the vasoconstrictors 
of the local blood-vessels, their walls relax, and for a short time the blood 
flows freer than normal {active hyperemia.) Soon, however, there is a 
slowing down of the current at the point of infection {passive hyperemia). 
When this last step takes place, the leukocytes pass from the blood-stream, 
accumulate around the walls of the vessels, and the migration of these body 
soldiers to the field of action is about to take place. Changing their shape 
they penetrate the endothelium of the capillaries, and soon emerge into 
parts where the bacteria have pitched their camp. In the meanwhile the 
transudation of serum around the area containing the invading bacteria and 
leukocytes is begun, and the battle for supremacy is on. 

The presence of bacteria with their toxins, the increased pressure from 
the serum which has been poured out from the engorged blood-vessels, the 
malnutrition under which the part is laboring because of the retarded circu- 
lation, and the numerous leukocytes which have migrated from the blood- 
vessels, all have a tendency to produce necrosis (breaking down) and lique- 
faction of the tissues. The leukocytes are performing their function, some 
repelling and some enveloping the intruding bacteria, while others are 
devouring and making away with this necrotic tissue. This function of the 
white blood-corpuscles is termed phagocytosis. If the virulence of the in- 
fection is severe, and the necrotic process with its liquefaction great, it is 
termed suppuration or pus; hence, the philosophy of the definition, "pus is 
the molecular death of a part in a state of solution/' From the very nature 
of things it must contain bacteria and their toxins, exudates, leukocytes of 
all kinds, necrosed or broken down tissues, besides other constituents of the 
blood. After the pus has been evacuated from an infected area, a cavity 
must result, which needs repair. (See lecture on "Wounds.") 



Artificial Hyperemia 15 

Artificial Means of Assisting Natural Resistance. — There are two means 
by which this may be accomplished at the present time — artificial hyper- 
emia and vaccines. 

Artificial Hyperemia. — I have purposely given you some idea of the con- 
ditions which occur during the process of an inflammatory action so that 
you may appreciate to some extent, at least, the theory of artificial hyper- 
emia as first suggested by Prof. Bier of Berlin. There are two principles 
to Be borne in mind, (1) an inflammatory action is simply a process on the 
part of Nature for self-defense, and (2) artificial hyperemia has for its 
object an increased amount of blood to a diseased area. By artificially in- 
creasing the quantity of blood to any diseased part the resistance of that 
part is raised, because (1) there is an increase of leukocytes and their 
alexins (in other words a local leukocytosis is produced), and (2) there is 
an increase of serum with its opsonins and other protective agents. There 
are two classes of artificial hyperemia, (1) venous or passive, and (2) 
arterial or active. 

Means for the Production of Hyperemia. — 

(1) The employment of an elastic bandage. 

(2) The application of vacuum-cups or cupping-glasses. 

(3) By utilizing superheated air. 

The elastic bandage or vacuum-cup produces a venous or obstructive 
hyperemia by retarding the blood-stream on its return to the heart. The 
superheated air causes an arterial hyperemia by producing dilatation of the 
blood-vessels. 

The Elastic Bandage — Rules for Applying the Same. — (1) The width of 
the bandage should vary according to the part to be constricted, and be of 
sufficient length to encircle the desired area two or more times. 

(2) The bandage is applied proximal to the infected area, that is to say, 
if the focus of infection is in the hand, the bandage is adjusted above the 
elbow ; if in the foot, it is applied somewhere above the knee ; if in the face, 
the neck is the point of constriction. 

(3) The bandage should be applied snug enough to slightly constrict the 
caliber of the veins, but not sufficient to obstruct the bore of the arteries, 
the pulsation of these latter vessels must always be distinctly felt below the 
bandage. In this way the arterial blood passes freely to the part, but the 
venous return is retarded, consequently the veins below the point of con- 
striction should stand out prominently, and the skin assume a bluish-red or 
dusky tinge. The application of the bandage should never produce pain, 
in fact, a properly applied bandage relieves this symptom at the point of 



16 Suction Apparatus 

infection, moreover the temperature of the part should be slightly increased, 
never diminished. 

(4) All dressings on the infected area which compress the part should 
be removed during the process of the treatment, because swelling ensues 
when artificial hyperemia is used. 

(5) During the intervals that the hyperemic treatment is suspended, the 
member should be elevated so as to favor the absorption of the swelling. 

(6) The part which has been compressed by the obstructive bandage 
should be gently massaged, or rubbed with alcohol. 

(7) The duration of each application will vary from four to twenty-two 
hours per day. 

Thus you can see, this form of treatment imitates the symptoms of an 
inflammatory process ; that is, there is an increase of heat, redness, and 
swelling, but with the absence of pain, and, as I have told you that inflam- 
mation is simply Nature's effort at self-defense, you will appreciate how this 
treatment is a reinforcement of her methods. 

Suction Apparatus or Cupping-glasses. — These are of various sizes and 
shapes, so as to fit the different contours of the body. They vary from the 
simple bell-shaped cup equipped with an ordinary rubber bulb (which when 
squeezed produces a vacuum within the cup after the latter is applied to the 
affected area), to some of the most elaborate suction apparatus, capable 
of holding a hand or foot, and equipped with metal pump and three-way 
stopcock. At the present time they can be obtained at any of the leading 
instrument houses. 

By applying a suction-cup or any of its modifications, and producing a 
proper amount of vacuum in the same, the skin and underlying tissues are 
drawn into the cup and assume a bluish-red color, due to the superabund- 
ance of blood sucked into the vessels supplying the tissues. A venous hyper- 
emia is thus produced without pain; but, if the suction is too intense, the 
pressure on the tissues will be so great that the blood-supply will be cut off 
and the part appear anemic and exceedingly painful, which is certainly not 
the desired end. 

This method of producing artificial hyperemia has a very extensive appli- 
cation, because it not only affords increased local resistance to an infected 
area, but, by its mechanical suction, it is capable of aspirating the contents 
of an abscess cavity through a very small opening which would otherwise 
have to be evacuated through a much larger exit. It therefore is an adjunct 
to cosmetic surgery. 



Vaccines — Wright's Hypothesis 17 

The rules for the application of these various forms of suction apparatus 
are similar to those already given for the application of the elastic bandage. 
To which may be added — 

(1) In using a suction-cup, anoint the skin over which the same is to be 
applied with vaselin to insure an air-tight application. 

(2) The duration of each application should be five minutes, six times 
per day. 

(3) After the use of a suction apparatus in suppurative cases, the glass 
portion should be sterilized by boiling and the rubber attachments thoroughly 
cleansed before being used again. 

Superheated Air Apparatus. — The hyperemia produced by this means 
is of the arterial variety, and is more indicated in chronic inflammatory 
affections than in acute inflammations. Its chief sphere is in the absorption 
of exudates, infiltrations, etc. The use of hot poultices, counter-irritants, 
stimulating liniments, etc., are only other means of producing arterial 
hyperemia, and their beneficial effects are due solely to their influence on 
the local circulation. 

Vaccines. — The use of vaccines to artificially increase the natural resis- 
tance of the economy was first suggested by Sir A. E. Wright of England. 
A vaccine, as at present understood, is a mixture of bacteria killed by the 
aid of heat and sterilized in some antiseptic solution; each cubic centimeter 
of which represents a definite number of germs. The microorganisms 
entering into the mixture being either obtained from the focal point of 
infection (autogenous vaccines), or from germs identical with those pro- 
ducing the inflammatory condition; the former being preferable. 

Wright's Hypothesis, — (a) An opsonin is one of the normal protective 
agents contained in the blood-serum, its action being to prepare bacteria for 
destruction when coming in contact with the leukocytes. 

(b) There is supposed to be a specific opsonin for each pathogenic 
bacterium; that is to say, one for the staphylococcus, another for the 
gonococcus, etc. This, however, is denied by some authorities who claim 
a multiple action for the opsonins ; in other words, a single opsonin being 
capable of acting on several pathogenic bacteria. This latter theory is 
gaining more general acceptation. 

(c) When the opsonins are up to a normal standard in the economy 
and the blood-serum is in no way interfered with, an infection will not 
occur, because the natural protective agencies are sufficient to protect the 
economy. 

(d) A deficiency of opsonins, or an inability of the blood-serum to 
transude around a focus where pathogenic bacteria have entered, permits 



18 Wright's Dictum 

the propagation of the invading microorganisms, and infection develops 
because the leukocytes are unable to cope with the invading host without 
the assistance of the blood-serum and its opsonin. 

The points, therefore, to be emphasized, are, (1) the function of the 
blood-serum and the protective agents it contains (in the presence of infec- 
tion) is to prepare bacteria for destruction by the phagocytes, which when 
accomplished is termed phagocytosis. (2) "The capacity of the serum to 
produce phagocytosis is spoken of as 'phagocytic index' and a comparison 
of the phagocytic index with another, or several others, from presumably 
normal individuals, gives the so-called 'opsonic index.' " — A. P. Ohlmacher, 
M. D. 

Wright's Dictum. — // in the presence of infection the opsonic index is 
below normal, the subcutaneous injection of a vaccine administered at 
proper intervals and in proportionate doses will raise the opsonic index, — in 
other words j increase the resisting power of the economy. 

Dose and Frequency of Administration. — The number of bacteria that 
is necessary to enter into a vaccine injection will depend entirely on the 
amount of resisting power the patient possesses, and the virulence of the 
infection, as indicated by a blood-count. The frequency of administration 
depends on the amount of reaction that occurs after an injection and the 
duration of such reaction. 

BIBLIOGRAPHY. 

American Practice of Surgery — James E. Moore, M. D. 
General Surgery — Lexer-Bevan. 

Blood-counting — J. J. Coons, M. D., Columbus, Ohio. 
Bier's Hyperemic Treatment — Meyer and Schmieden. 
Practical Bacterial Therapy and The Theory of Opsonins — A. P. Ohl- 
macher, M. D., Detroit, Mjch. 



LECTURE III 

ANTISEPTICS, DISINFECTANTS, GERMICIDES, DEODORANTS, 

STERILIZATION 

A disinfectant or germicide is a chemical agent which destroys the vitality 
of bacteria. 

An antiseptic is a drug which retards the growth of bacteria. 

A deodorant is a substance which destroys offensive odors. Occasionally 
a drug possesses all three characteristics, — carbolic acid is an example. 
When used in a strong solution (5 per cent.) it is germicidal ; in a 1- or 2-per 
cent, mixture it is an antiseptic, while its natural odor makes it a good 
deodorant. 

From the time (1865) Lister wrote his ''Germ Theory of Disease" the 
profession has been looking for some drug which is capable of destroying 
bacteria, and at the same time be harmless to the tissues. The manufactur- 
ing pharmacists have not been slow with their commercial ideas, and have 
placed on the market numerous proprietary nostrums, none of which are 
valuable as germicides ; this fact I desire to impress on you, because in 
surgical nursing your opinion may be asked by the family along these lines. 
Never under any circumstances advise a family to invest in these patent 
drugs. 

In giving a list of antiseptics I have endeavored to mention only those 
that are in common use by the profession. 

Bichlorid of Mercury (Corrosive Sublimate) undoubtedly is the favorite 
American disinfectant. It has its limitations inasmuch as it is highly 
poisonous, extremely irritating in strong solution, and corrodes instruments. 
It is put on the market for surgical use in 7^ -grain tablets; by the addition 
of an equal amount of citric acid or chlorid of ammonia the mercuric salt 
is made more soluble, besides preventing to some extent the formation of 
an albuminate of mercury when used in the irrigation of wounds. The 
addition of anilin-blue to these tablets should always be insisted on, because 
it identifies the solution from others used in the operating-room. As an 

(19) 



20 List of Antiseptics 

irrigation for infected wounds it should never be used in a stronger solution 
than 1 :5000. Some surgeons, however, use it in a stronger solution. 

Biniodid of Mercury. — Through the efforts of McClintock this drug has 
been brought to the notice of the profession as a germicide. The claims put 
forth are: it is five times more germicidal, does not produce an albuminate 
when in contact with fresh tissue, is not irritating, and will not corrode 
instruments; none of these desirable features are found in bichlorid of 
mercury. When a solution of this latter drug comes in contact with bac- 
teria it immediately coagulates the albumin on the cell-wall which pre- 
vents the germicidal action of the solution from penetrating into the 
protoplasm of the cells; besides, as I have mentioned, it is extremely 
irritating and capable of producing a thin film of necrosis, even in very 
attenuated solutions, hence it seems probable that this new preparation 
(biniodid) is destined to supersede the old drug. The only drawback that 
has been attributed to it, is its lack of permanency, so that it cannot be kept 
indefinitely. It is marketed in tablets, or discs, having the following formula : 

Mercuric Iodid gr. ^ 

Potassium Iodid gr. y% 

Sodium Bicarbonate grs. 16 

Carbolic Acid, Creolin, and Lysol are mentioned together because they 
are closely related, being derivatives of coal-tar. 

Carbolic Acid can be mixed with water to the extent of a 5-per cent, 
solution, in which strength it is a disinfectant. It is irritating to fresh 
tissue, and as an irrigating solution in wounds it should not be used 
stronger than 2 per cent. Its antidote is alcohol, which must be applied 
freely. 

Creolin and Lysol are used chiefly by obstetricians. When mixed with 
water these drugs make a soapy, oily solution, more suitable for vaginal 
douches than either carbolic acid or the mercuric preparations, these latter 
constrict the vaginal canal. Lysol is used in from 1- to 3-per cent, solution ; 
for repeated vaginal irrigation a 0.50-per cent, solution (-J%) is the maxi- 
mum strength that the average patient will tolerate. Creolin is less irritat- 
ing than either carbolic acid or lysol, and probably possesses less germicidal 
qualities. It may be used in strengths varying from 2 to 4 per cent. 

Iodin. — 1 desire to call your attention especially to this drug, because it 
is being used more and more as a germicide. Some of its ardent advocates 
claim it does not produce necrosis in wound cavities as other antiseptics, and 
has a more penetrating effect in freshly cut tissues than any other germi- 



List of Antiseptics 21 

cide. If the advice of army surgeons is accepted, all other disinfectants 
would practically be discarded in favor of this drug. I have used it in 
suppurating cavities for the last fifteen years, and as a final step in prepa- 
ration of the field of operation. I think it deserves more general use than 
has been accorded it. It should also hold an important position in coun- 
try practice, where aseptic conditions cannot be thoroughly obtained, 
or in emergency surgery in factories, where everything that surrounds the 
injured is septic. The officinal tincture is the preparation used. A solution 
of the tincture with benzin or gasolin (from 1 to 3 per cent.) is employed 
by some surgeons at the present time in the preparation of the field of 
operation, the philosophy of which will be given in the lecture devoted to 
the "Preparation of the Patient for Operation.'' 

Formaldehyd is a powerful gas, and in this form is used to disinfect 
rooms, clothing, etc., after contagious diseases. An aqueous 40-per cent, 
solution is made and sold under the name of Formalin. This solution is 
used as a disinfectant in strengths varying from 1 :2000 to 1 :200. For- 
malin was more popular formerly as a general surgical antiseptic, but 
its intensely irritating nature and the harshness it imparts to the tissues 
prevent its general adoption. 

Evaporating Lotions may be classed as antiseptics. Their chief ingredi- 
ents being boracic acid, alcohol, and menthol, diluted with water, render 
them mildly antiseptic ; they also form a pleasant dressing for sprains, con- 
tusions, abrasions, and superficial infections after the parts have been put 
at rest. The following formula is recommended: 



3 



Boracic Acid 5 4 

Glycerin 5 11 

Water pts. 8 

Mix and boil 15 minutes. 

Add Alcohol I 11 

Menthol 5 1 

Mix and filter. 



Harrington's Solution. — This is being used by some of the leading 
surgeons of the country as a disinfectant for preparing the field of opera- 
tion and for hand sterilization, with excellent results. The formula was 
designed by Harrington of Boston. Its capacity for destroying bacteria is 
twenty times greater than any known germicide — a most admirable feature. 
It is no more irritating than any other drug of this class. Unsterilized hands 
washed in this solution for the period of one minute, become sterile, so that 
no bacterial growths can be obtained from the scrapings made from such 



22 List of Antiseptics 

hands. Clinical experience seems to bear out these statements. The fol- 
lowing is the formula : 



5 



Bichlorid of Mercury .grs. 48 

Hydrochloric Acid § 8 

Water (distilled) pts. 2^ 

Alcohol pts. S]/ 2 

Mix. 



Potassium Permanganate is a purple polyhedral crystal: It is used in 
solution from 1:100 to 1 :10, chiefly as an antiseptic for the hands, which 
it stains a deep purple. This drug was more popular formerly than at 
present. The stain it leaves after sterilizing the hands is decolorized by 
the next drug I will mention. 

Oxalic Acid. — This is a very poisonous and irritating drug, although it 
is claimed to be a highly efficient germicide. When potassium permanganate 
and oxalic acid were first used in the preparation of the surgeon's surgical 
toilet, many controversies arose as to which was really the disinfectant; 
eventually it was decided in favor of the latter. 

Chlorid of Lime — Carbonate of Soda. — When these are mixed together 
in equal proportions and moistened with water to form a paste, chlorin 
gas is eliminated, which possesses high disinfectant qualities. This combi- 
nation forms a favorite germicide for hand-sterilization among some sur- 
geons. The readiness with which these drugs can be purchased at any drug 
store only enhances the value of this method in operations occurring remote 
from hospital service. 

Argyrol is a definite chemical compound of silver, containing 30 per 
cent, of that metal. The various combinations of silver possess more or 
less antiseptic qualities and are irritating to the tissues to a greater or less 
extent. This preparation, however, is very efficient as an antiseptic and 
practically non-irritating. It does not precipitate albumin or sodium 
chlorid, another very meritorious quality. It is used chiefly in infections 
of the mucous membrane, in solutions varying in strength from 2 to 50 
per cent. It permanently stains linen. Solutions deteriorate rapidly, and 
should be freshly prepared when needed. 

Hydrogen Dioxid (Aqua Hydroganii Dioxidi) is a useless article when 
employed as an antiseptic or disinfectant. It has no such properties, and 
really should not be classified with them. The sphere of its usefulness 
lays in the fact that it eliminates its oxygen freely when in contact with 
organic matter. It is therefore useful to remove blood-clots, necrosed 



Method of Making Solutions 



23 



tissue, and other debris in wounds and ulcers. It possesses hemostatic 
qualities, and may be utilized in minor venous oozing. 

APPROXIMATE WAYS OF MAKING ANTISEPTIC SOLUTIONS BY 
APOTHECARIES' MEASURE. 



To make 1 
To make 1 
To make 1 
To make 1 
To make 1 
To make 1 
To make 1 
To make 
To make 



oz. 
pt. 

qt. 

qt. 
qt. 

qt. 

qt. 
lqt. 
lqt. 



of 

of 
of 
of 
of 
of 
of 
of 
of 



1:500 
1:500 
1:500 
1:1000 



2000 
3000 
4000 
5000 
10,000 



solution use 
solution use 
solution use 
solution use 
solution use 
solution use 
solution use 
solution use 
solution use 



1 grain 

1 5 grains 

30 grains 

15 grains 

7^4 grains 

5 grains 

3% grains 

3 grains 

\y 2 grains 



of the drug, 
of the drug, 
of the drug, 
of the drug, 
of the drug, 
of the drug, 
of the drug, 
of the drug, 
of the drug. 



To make 
To make 
To make 
To make 
To make 
To make 



y 2 grain (plus) 
1*4 grains 



PERCENTAGE SOLUTIONS (APPROXIMATE ONLY) 

1 dram of a 1% solution use 

1 dram of a 2% solution use 

1 dram of a 4% solution use iy 2 grains 

1 oz. of a 1% solution use 5 grains (minus) 

1 oz. of a 2% solution use 9 T / 2 grains 

1 oz. of a 4% solution use 19 grains 



of the drug, 
of the drug, 
of the drug, 
of the drug, 
of the drug, 
of the drug. 



N. B. — Occasionally 0.1-per cent. (1/10%) solution is required. In such 
a case make 1 dram of a 1-per cent, solution, and dilute it 9 times, — that is, 
add 9 drams of water. 

Metric System. — This is so simple that every one should use it, although 
the long list of tables given in text-books for converting apothecaries' into 
metric measure, or vice versa, bewilders the average student. For prac- 
tical purposes the following table is approximately correct: 

METRIC SYSTEM. 



Solids. 



Approximate 
Equivalent. 



1 grain 0.065 gram 

1 ounce 30. grams 

1 pound 500. grams 



Liquids. 



Approximate 
Equivalent. 



1 minim .... 0.06 c.c. 

1 ounce .... 30. c.c. 

1 pint 500. c.c. 

1 quart 1000. c.c. or 1 liter 



EXAMPLES. 



To make 1000 c.c. (1 liter) of a 1 :500 solution use 2 grams of the drug. 
To make 1000 c.c. (1 liter) of a 1 :1000 solution use 1 gram of the drug. 
To make 1000 c.c. (1 liter) of a 1 :2000 solution use J / 2 gram of the drug. 



24 Abuses of Antiseptics 

Thus remembering these approximate equivalents, you can at once produce 
a solution of any required strength ; on the other hand, if the time-honored 
apothecaries' measure is used, a mathematical problem is practically neces- 
sary to gain the desired end. 

Dusting-powders. — Among antiseptic dusting-powders may be mentioned 
B oracle Acid, a highly useful drug, for while it is only slightly antiseptic, 
it is many times less irritating than others of its class, and practically non- 
poisonous. It is a white, odorless powder (as used in surgery), and for this 
reason can be utilized where other dusting-powders would be objectionable. 
It is commonly used in solution as an antiseptic wash, but for it to have 
any antiseptic properties it should be a saturated solution (4 per cent). 
In the many operations on the eye it is practically relied on in the ante- 
operative preparation to cleanse that organ while in gastric lavage as a 
preparatory step to gastroenterostomy, it is universally employed; the 
urinary bladder is cleansed with irrigations of this drug when operations 
on that viscus are necessary. 

Iodoform as prepared for surgical use is a yellowish powder, with a disa- 
greeable odor. It is rich in iodin, and for this reason is extremely irritating 
to the skin, often producing a local eczema; nevertheless when it is used 
in suppurating cavities in the form of iodoform gauze, it has very beneficial 
results. 

Aristol (Dithymoldiiodid) may be mentioned as a dusting-powder with 
similar action to iodoform. It is of a brownish-red color, less offensive, 
but has never supplanted the former. 

Dusting-powders are not frequently used, because their presence is an 
irritant to the raw tissues ; they form crusts, prevent the exit of any secre- 
tions from the stitch-holes and wound, and thus favor the formation of pus. 

Abuses of Antiseptics and Germicides. — No class of drugs that has any 
connection with ante- or postoperative treatment of surgical cases has been 
so abused as those I am now considering. They are useful and necessary 
in their place, and their place is limited. They are harmful and pernicious 
when used irrationally. The cleaner a surgeon or nurse is by instinct, the 
less will they use antiseptics; the more slipshod they perform their duties, 
the more will they rely on these chemical agents. The cleansing of an 
infected wound with a strong antiseptic solution never accomplishes the 
purpose for which it is employed, i. e., the sterilization of the wound, 
because in infected wounds or cavities albuminous deposits and broken- 
down tissues are present which serve as a suitable culture-media for the 
propagation of microorganisms, and beneath which the bacteria are 
sheltered. The local tissues also have lost their normal power of resistance, 
consequently no barrier is interposed to the microorganisms penetrating this 



Mechanical Antiseptics 25 

semi-devitalized area, remote still further from any effects of the antiseptic 
solution. If the germicide be very strong and irritating, further necrosis 
is developed, more debris is formed, and still more devitalization of tissue 
occurs, so that instead of producing a sterile field, a fertile bed is being 
developed for the propagation of bacteria. The most an antiseptic solution 
accomplishes in the presence of infection is to remove in a mechanical way 
debris, blood-clots, necrosis, and such microorganisms as lay superficially, 
but this can only be accomplished with a mild, non-irritating solution, other- 
wise further necrosis and devitalization occur. The greater the infection 
in wounds and other cavities, the milder should be the antiseptic used for 
irrigation, but the larger should be the amount of solution employed. Quan- 
tity and not strength is the keynote. The lesson taught, therefore, is self- 
evident : the employment of mild, warm, non-irritating antiseptic solutions 
in large volumes, mechanically ridding the infected area of necrosis, and 
rejuvenating the underlying semi-devitalized tissues. On the other hand, 
strong antiseptic solutions are used to cleanse the hands of the operator 
and his assistants, and the field of operation. 

The more that is known of antiseptics, and the more infection is 
studied, the more will surgical cleanliness become the weapon against 
infection. 

Mechanical Antiseptics. — By the term "mechanical antiseptics" I intend 
to imply such measures as produce an antiseptic condition outside of 
chemical agents. The most common form is the ordinary hand-brush with 
soap and water. There are many surgeons today, probably the majority 
of them, who rely on this simple method mainly for the sterilization of 
the hands and the field of operation. A rather stirT-haired brush is em- 
ployed with any kind of soap. I desire to impress on you the fact that it 
is not the kind of soap that will produce a sterilized condition of the hands 
or field of operation, but it is the kind of methodical scrubbing with which 
the soap and brush are applied to the parts. 

The Sterilizing-room. — This should be a large apartment without any 
unnecessary furniture, easily accessible to the main operating-room; in 
fact, should communicate with it by a doorless opening to allow the surgeon 
or his assistants to pass to and fro without having a door to open and thus 
contaminate their surgical toilet. The floors of such an apartment should 
be tile, the walls enameled and so constructed as to leave no sharp corners 
with the floor or with each other. Woodwork must be dispensed with as 
far as possible, so that no crevices are left. 

When such a room does not communicate with the operating-room it is a 
common occurrence to see nurses who have carefully sterilized their hands 
and assumed their gowns, passing backward and forward through the 



26 



The Sterilizing-room 



corridors for necessary supplies. This is wrong, slovenly, and careless, 
for in a thoughtless moment their attire may be infected by coming, in con- 
tact with visitors, nonsterile nurses, and patients. All furniture should be so 



i 



Illustration I 

Sterilizing-room. — Observe the battery of sterilizers, porcelain sink, cup- 
boards for dressing's and instruments, and shelves for such medicines as 
are used in surgery. See illustration XLIII for the relation of this room 
to the operating-room. 



constructed as to facilitate the cleansing of the apartment as thoroughly as 
the main operating-room. All cupboards for dressings and instrument- 
cases elevated on six-inch casters and of such height as to easily permit the 
cleansing of the top, — a location prone to collect dust. A satisfactory size 



Sterilizing-room 27 

would be 5 feet 6 inches tall, 6 feet wide, and 20 inches deep, made of steel, 
enameled white, with movable shelves, glass doors and sides. 

Necessary Furniture. — (1) A complete sterilizing outfit, connected with 
the boiler in the basement, for water, dressings, pitchers and basins, and 
instruments. This is so constructed that no superfluous steam is seen in 
the sterilizing-room. (See illustration I.) 

(2) A cupboard for the storage of sterilized articles, such as dressings, 
sponges, gowns, suits, caps, gloves, etc. (The number of cupboards re- 
quired for this purpose will vary according to the amount of surgical work 
performed in the hospital.) 

(3) An instrument case for surgical instruments, needles, catgut, etc., 
unless a special room is devoted to instruments. 

(4) A porcelain sink of suitable size elevated on metallic legs placed a 
sufficient distance from the wall to prevent an accumulation of debris, 
equipped with foot control of water faucets. This is utilized for cleansing 
the instruments after operation. 

(5) A four-shelf glass stand on which is placed drugs and other para- 
phernalia commonly used in the surgery. This is the location of choice 
for such a piece of furniture, — not in the operating-room. The following 
is a partial list of supplies which should always be found on this stand : 

Stock Solutions and Mixtures. — 

Stock Salt Solution. 

Saturated Solution of Boracic Acid. 

Evaporating Solution. 

Harrington's Solution. 

Iodin-Benzin 5-per cent. Solution.* 
Drugs and Chemicals. 

Carbolic Acid. 

Lysol. 

Tincture of Iodin. 

Formalin. 

Mercuric Tablets. 

Oil of Turpentine. 

Alcohol. 

Hydrogen Dioxid. 

Tincture of Green Soap. 

Glycerin, ~1 

Olive Oil, Y Sterilized by boiling. 

Vaselin, J 



* This solution is used by some surgeons in the final preparation of the field of opera- 
tion. (See lecture on "Preparation of the Patient") 



28 Sterilizing-room 

Drugs and Chemicals. 
Ichthyol. 
Argyrol. 
Silver Nitrate. 
Ethereal Collodion. 
Whiskey and Brandy. 
Solution Adrenalin Chlorid. 
Iodoform. 
Aristol. 
Boracic Acid. 

Hypodermic Tablets. 

Strychnin Sulph. gr. 1/30. 

Morphin Sulph. gr. 1/4. 

Morphin gr. 1/4 and Atropin gr. 1/150. 

Atropin gr. 1/150. 

Nitroglycerin gr. 1/100. 

Hypodermic syringe and needles. 

Local Anesthetics. 

Cocain Hydrochlorid. 
Eucain Beta. 
Novocain Hydrochlorid. 

Quinin and Urea Hydrochlorid. This last is only mentioned to be 
condemned, its after-effects produce sloughing of the tissues. 

Gauze Preparations. 

Iodoform gauze in small containers, 1 yard each. 
Iodoform gauze-tape in small containers, 1 yard each. 
Plain sterile gauze-tape in small containers, 1 yard each. 

Accessories. 

Urethral catheters (rubber and glass), assorted sizes. 

Drainage tubes (rubber). 

Colon tube. 

Stomach tube. 

These articles are sterilized and preserved in glass containers, filled 
with sterile glycerin. 

One set assorted graduates. 

Roller bandages, assorted sizes, kept in suitable containers. 

Adhesive plaster in 10-yard rolls (12 inches wide), and spools of 
assorted widths. 



Sterilization by Heat 



29 



Sterilization by Heat. — By the term sterilization is meant the destruc- 
tion of all bacteria in any given substance, generally by heat. I would 
divide this process into three heads, viz. — 

/<1N „ ,. . , P ,. f (a) Steam under pressure. 

(1) Heat eliminated from live steam. 



(b) Steam without pressure. 

(2) Sterilization by direct contact with boiling water. 

(3) Sterilization by dry heat. 




Illustration II 
Autoclave 



Sterilization by steam under pressure is obtained at the present time in 
hospitals by means of sterilizers attached to the boiler-room, hence it is 
steam under pressure, and it is the best method of sterilizing dressings, 
gowns, etc., which are used in the operating-room. Steam under pressure 



30 Sterilization by Heat 

can be forced through all the crevices and layers of the material, and its 
effects are immediate as compared with dry heat. The time necessary for 
sterilization in live steam under pressure should never be less than 20 
minutes, and preferably jo minutes. (See illustration II.) 

Such sterilizers are known as autoclaves. They will give a steam pres- 
sure of 10 to 15 pounds at about 250° F. The materials, after being 
sterilized, should be dry; if moist, it is due to a faulty mechanism in the 
sterilizer ; this fault can be overcome by allowing the dressings, gowns, etc., 
to remain in the autoclave an hour or two after the steam has been turned 
off, the heat of which will consume the moisture. 

Sterilization by Steam Without Pressure. — Occasionally you will be called 
upon to sterilize the different articles necessary for an operation at the home 
of the patient. A simple way to do this is to place two bricks edgewise in 
an ordinary wash-boiler in about two inches of water, place several strips 
of wood across these to form a foundation or bridge on which to rest the 
material for sterilization. Adjust the lid and place on the stove; after the 
water boils put in the materials for sterilization. This is not steam under 
pressure, hence the heat will not permeate as thoroughly and rapidly as in 
the autoclave. It is an erroneous idea to imagine that pressure of any 
consequence can be obtained in an ordinary clothes-boiler with a loose- 
fitting lid; more time is therefore required. Two methods are open for 
you to follow: (1) By sterilizing the materials for one hour, care being 
taken to watch the amount of water in the boiler. Or (2) repeat the 
above process the next day for a similar period. This latter method is 
known as fractional or intermittent sterilization. In both cases your dress- 
ings will be moist ; by placing them in an oven the dry heat will absorb the 
moisture. The fractional or intermittent method has for its object the 
destruction of bacteria present at the time of the first sterilization ; an 
interval of sufficient length (generally twenty-four hours) will permit any 
spores that may be present to develop, which are killed at the second or 
third sterilization. 

Boiling Water. — This method of sterilization is still quicker than live 
steam. Dressings should never be sterilized in boiling water unless under 
the rarest conditions in private practice, and then they should be dried 
previous to being used. Boiling water is the ideal means of sterilizing 
instruments, basins, and pitchers. Sharp-edged instruments such as knives 
and scissors are not boiled, as this process dulls their edges. The time of 
sterilization in boiling water is from ten to fifteen minutes. 

Dry Heat as a means of sterilization is not used in hospitals, but in private 
practice (especially in the country) the domestic oven is constantly called 
into service, not only to assist in sterilization but to dry such articles as have 



Sterilization by Heat 31 

been steam sterilized. It is a poor substitute for any kind of steam; the 
penetration of this kind of heat is slow ; the liability of burning the fabrics 
great, nevertheless you will be called on to use it occasionally. The most 
thorough way is the fractional method spoken of above, but I would repeat 
the exposure of the materials to the heat for one-and-one-half-hour periods, 
with as long an interval as possible between such exposures. 

In stating the time necessary for sterilization by the different methods, 
/ have purposely exceeded the limits usually laid down; my experience in 
hospital practice warrants me in doing so. It is far better to err on the 
safe side, and be conservative, than be hasty and jeopardize the results of 
the operation. 



LECTURE IV 
ASEPTIC AND ANTISEPTIC SURGERY 

Since I have spoken of antiseptics and disinfectants, it would be proper 
to call your attention to what is known as Aseptic and Antiseptic Surgery. 
By the term asepsis is meant freedom from infection, "the absence of 
living pathogenic bacteria," — surgical cleanliness. 

So that the modern acceptation of aseptic surgery implies an endeavor 
has been made to sterilize everything connected with an operation previous 
to operating; the hands of the surgeons and nurses have been thoroughly 
sterilized; the field of operation has been carefully prepared, possibly by 
means of antiseptics; the dressings, suture materials, and instruments have 
gone through a process of sterilization in an endeavor to maintain sterility 
of everything connected with the work. In spite of all this, it can probably 
be stated that there is no such condition as perfect asepsis. There is a 
limitation to our efforts along this line, and the most that can be accom- 
plished is to render the bacteria present either harmless, or keep them in 
check to such an extent that the resisting force of the economy can overcome 
their virulence or number. 

Once the operation has begun no antiseptics are used, because the first 
preparations are considered thorough enough to produce an aseptic condi- 
tion. On the other hand an operation may be begun and all the details of 
aseptic surgery carried out to a certain point, when asepsis has to be relin- 
quished, as in operations for pyosalpinx or suppurative appendicitis, where 
the presence of pus makes the use of antiseptic measures necessary in the 
further steps ; aseptic surgery then gives way to antiseptic surgery. 

By antiseptic surgery is implied that germs have gained entrance into a 
wound and antiseptic measures are used, either to destroy them if possible, 
or reduce their virulence. As an illustration, a patient with a wound is 
brought to the hospital; the logical inference is the skin is not surgically 
clean, nor the instruments or means by which the injury was inflicted sterile, 
hence, the wound is considered infected, and antiseptics are used to cleanse 
the parts. Antiseptic surgery is therefore practiced. To be concise, anti- 
septic surgery presupposes bacteria are present in the wound or field of oper- 
ation and an endeavor is made either to destroy them or retard their growth 

(32) 



Aseptic and Antiseptic Surgery 33 

by antiseptics; whereas in aseptic surgery there is every reason to believe 
that the wound is clean and efforts are made to keep it so. You will soon 
discover the fact, when doing practical work, that asepsis and antisepsis go 
hand in hand, and very few operations are performed where both methods 
are not employed. 

The numerous procedures utilized in the practice of aseptic surgery are 
called the "chain of asepsis," each individual step is known as a link. Sur- 
geons and nurses should ever be on the alert to see that no link is broken, 
for remember "the strength of a chain is its weakest link" : the thoroughness 
of asepsis is measured by its weakest step. Remember, too, the natural tend- 
ency is towards retrogression, unless the strictest care is exercised ; nowhere 
is this more prone to show itself than in the routine of professional life. In 
hospital and private practice rules are laid down for the proper method to 
obtain the best aseptic conditions. So long as such rules and methods are 
carried out the results are gratifying. Sooner or later this or that trifling 
step is omitted, then another is overlooked, until the former perfect chain is 
weakened or possibly broken, so that instead of an aseptic technic there is 
left only a septic routine. This careless condition does not develop sud- 
denly : it grows insidiously, until a high death rate or the prevalence of infec- 
tion following operations, attracts attention. On close examination and in- 
quiry into prevailing methods, some glaring errors which have stealthily 
crept in are discovered. From the moment a surgical patient enters the hos- 
pital, or you are called to the home to render professional care, the strictest 
aseptic rules should obtain until convalescence is thoroughly established. 

Let me illustrate by examples which have come under my observation. In 
a hospital where I am more or less frequently called, I seldom or never 
operated but that infection developed before convalescence was established. 
This is the reverse of the results obtained at the hospital where the majority 
of my work is done, and I felt sure some faulty technic was responsible, yet, 
on going over the routine with the physicians and nurses in charge, no cause 
could be discovered for the untoward results that others and the writer were 
having. On one occasion I happened to overhear one of the senior nurses 
order a patient (who had just arrived) to adjourn to the bathroom and take 
a general bath before being put to bed. Being interested, I asked if all 
patients were so treated, and received an affirmative reply; further inquiry 
revealed the nature of the patient's illness to be one of leg ulcers. Without 
further comment I waited until the patient was put to bed, to see how the 
bathtub would be cleansed : it was ready for use after being rinsed with 
warm water. Later the soiled and pus-besmeared bedclothes from the bed 
of a patient suffering with septicemia were thrown in the bathtub to await 
the orderly whose duty it was to remove them to the laundry. I did not 
have time to see how the tub would next be employed, but I was now sure 



34 Aseptic and Antiseptic Surgery 

the solution of my problem was in sight, and the cause of the numerous 
cases of infection discovered. It was horrifying and disgusting, possibly it 
would be nearer the truth to say it was criminal. A reform was instituted, 
the general bathtub abandoned, and the results from this time on were 
excellent. 

It is just in this connection that I desire to emphasize a fact which I believe 
to be true: hands that have become infected with pits remain so for three 
days, in spite of all the ordinary methods of cleansing, and whether they are 
or not, it is your duty to believe them infected; hence the employment of 
rubber gloves is compulsory. Without the use of these articles infection can 
be carried from one to another, thus producing what I have already de- 
scribed as a secondary infection, 3. very serious complication. 

An incident that goes to show how carelessness can creep in after ironclad 
rules have been established is the following: A patient was sent me from the 
southern part of Ohio to be operated on for gall-stones. She was ordered 
prepared for operation the next morning, and having occasion to visit an- 
other ward I noticed "Nurse A" cleansing a suppurative wound with 
ungloved hands. It was not my patient, but knowing she was breaking a 
rule of the hospital in not wearing gloves while doing a dressing, I felt it 
my duty to call her attention to the infraction, but failed to do so at that 
time. I continued making my rounds until eventually I returned to the 
room of my patient for operation, when to my horror I discovered "Nurse 
A," who a few minutes before had been cleansing the suppurating wound, 
now preparing the abdomen of my patient with her hands still ungloved. 
On questioning her I elicited the fact that she was not using the same basins 
as in the suppurative case, and the only cleansing her hands had received 
was a little soap and water, and finally an immersion in a carbolic-acid solu- 
tion. I may add the operation was deferred for three days, during which 
time the patient received careful antiseptic cleansing, and finally convalesced 
without any suppuration. The reverse might have been true if my atten- 
tion had not been accidentally directed to this. 

Moreover the omission of gloves in the nurse's technic, when dressing 
suppurative wounds, has caused primary infections in clean wounds of other 
patients, an illustration of which I desire to cite : A patient was suffering 
from an infected wound due to the presence of gonococci and staphylococci 
(mixed infection) ; the nurse was ordered to cleanse the infected area, which 
she did with ungloved hands. She was next directed to remove the coap- 
tating stitches from a clean abdominal incision of another patient, and this 
she also accomplished without the use of sterile gloves. Three or four days 
later this patient developed an acute infection which resulted in suppuration. 
The microorganisms present were the same as in the first case. There being 



Aseptic and Antiseptic Surgery 35 

no other infection on the floor, it was easy to trace the source of the infec- 
tion and to see where the chain of asepsis was broken. 

I hope I will not be considered tiresome if I cite another case, — similar in- 
cidents possibly occur daily in hospitals where the strictest supervision is not 
kept over the student nurses : A patient was to have a celiotomy performed 
the following day. It was late in the afternoon, and having to wait for a 
train, with nothing to occupy my time, I thought I would watch the day 
nurse prepare my patient. She went to the bathroom, filled two basins, — 
one with sterile water in which she put soap and brush, and the other with 
a solution of corrosive sublimate, — adjusted a pair of gloves, and repaired to 
the room to begin preparations. When asked how she knew the basins were 
sterile, she frankly replied, "They ought to be, they look so." On demand- 
ing to see the rules as laid down by the institution it was distinctly stated 
that all basins should be boiled before such preparations were made, but on 
account of the lateness of the hour this nurse had willfully or thoughtlessly 
overlooked this, and thus jeopardized the results of the operation. These 
innocent-looking receptacles are, unless sterilized, patent agents in the dis- 
semination of infection. 

I would not have you think the nurse is the only careless individual in 
hospital practice — far from it; some of the most glaring instances of dere- 
liction can be placed at the door of those higher in authority. Let me cite 
some of the most common errors : 

A properly equipped hospital should have closets in which are placed large 
galvanized iron pails (with fitted covers) as receptacles for the soiled dress- 
ings, etc. These closets should be used exclusively for this purpose, and 
not as storerooms for brooms and dust-cloths which are employed for 
cleansing the apartments. What good is obtained by fumigating an apart- 
ment for twenty-four hours with formaldehyd gas, and then use the dirty 
brooms from the "pus-closet" to sweep it? This is not the nurse's fault, it 
is due to the carelessness of the officials. 

Another fertile source for a break in the chain of asepsis is the employ- 
ment of damaged rubber gloves. It grates on one's sensibilities to witness a 
surgeon or nurse professing to be aseptic using these. They seem to think if 
the major portion of their hands are covered they are affording their patient 
ample protection. 

Again, if it be necessary to devote a special room to the surgeon and his 
assistants in which to change their clothing, sterilize their hands, and gown 
themselves, why should not the same accommodations be granted the nurse? 
In other words, why should the surgeon have an aseptic room to prepare his 
toilet, and the nurse not have the same privilege, instead of being forced to 
retire to her bedroom to change her uniform and assume an operating gown ? 
Why should the surgeon consider it necessary to change his 'lothing first, 



36 Aseptic and Antiseptic Surgery 

then sterilise his hands, and finally gown himself, while the nurse is per- 
mitted or forced to assume her sterile gown before cleansing her hands? 
This break in the technic could be obviated by the use of a bib-apron 
assumed after the sterilizing process. The fault lies at the door of the 
officials whose duty it is to prevent such errors and inconsistencies. These 
examples are cited to demonstrate how easily the rules of asepsis can be 
broken; to demonstrate the necessity of keeping a strict watch over every 
detail concerning surgical patients ; to suggest clues for possible trouble, and 
to demonstrate that the aseptic patient is in constant danger of becoming 
septic. 

What is true of hospital routine is just as applicable to private practice, 
only from other sources. The most careful nurse can have her work go for 
naught by some member of the family immersing his or her dirty hands in 
the sterile water to ascertain its temperature, or through curiosity unfold a 
package of dressings or handle some sterilized instrument, thus breaking the 
chain of asepsis which has taken hours to consummate. So it behooves 
the nurse doing private surgical work, not only to do her work thoroughly, 
but also to insist that members of the family refrain from meddling with her 
duties. This can be done in a nice, cordial manner, so as not to offend, yet 
with a firmness that indicates her to be responsible for results in the 
absence of the surgeon. 

I know of no place more appropriate than here to state that it is the sur- 
geon's privilege to choose his own surgical nurse, when operating in private 
practice ; — one who is well acquainted with his technic, one who ap- 
preciates his high ideals of asepsis — and not allow the family to dictate a 
nurse who is unacquainted with any of the special methods employed by 
the operator. It is unfair to the nurse, unjust to the patient, unsatis- 
factory to the surgeon, and above all, the results are generally imperfect. 

In the lectures on "Preparation of Patient for Operation" and "Technic 
of the Operating-room," full details will be given as to the best methods 
to be employed to carry out a perfect chain of asepsis, and implicit 
instructions detailed as to each step, and the value of each procedure. 

BIBLIOGRAPHY. 
American Practice of Surgery — James E. Moore, M. D. 



LECTURE V 

PREPARATION AND STERILIZATION OF GOWNS, SPONGES, 

DRESSINGS, AND OTHER ARTICLES COMMONLY 

USED IN SURGERY 

Having tried to impress on you the necessity for asepsis and the dangers 
incident to any break in the chain of thorough cleanliness, I desire to go into 
details as to the methods employed in the preparation and sterilization of 
such articles as are kept ready for any emergency or contingency which 
may arise* 

Gauze.— At the present moment this is used exclusively for sponges, dress- 
ings, and even bandages. It is soft and pliable; when utilized as a sponge 
or dressing it instantly absorbs any fluid with which it comes in contact. 

There are variable grades of this material on the market, each having a 
different mesh. It is an erroneous idea when ordering to specify by number, 
as each maker has a different prefix to indicate the different grades, and fre- 
quently mistakes are thus made. The number of the fibers entering into a 
square inch of gauze will of course govern its mesh, and this is the proper 
way of identification. That is to say, gauze having 20 fibers running length- 
wise in an inch, and 14 transversely, will give an open large mesh ; while one 
having 36 fibers interlaced by 32 similar strands to the given space will pro- 
duce a closer weave. The standard and recognized meshes are as follows : 
14 by 20, 20 by 24, 24 by 28, 32 by 36, and 40 by 44. The 14 by 20 mesh is 
used chiefly for sponges as it absorbs more rapidly, while the 20 by 24 is the 
one utilized for dressings, its mesh being closer. Bandages are made from 
the 40 by 44 mesh. 

Some hospitals after using their dressings and sponges laundry the same 
and utilize them again after being sterilized. While I have no doubt they 
can be thus made surgically clean, the thought is repulsive and should not be 
countenanced. 

Gowns. — These are made from a good quality of muslin or preferably 
linen. There are various styles made to suit the taste and fancy of the indi- 
vidual, which of course is of minor importance from a practical standpoint. 
Whatever style is adopted, it should be full length with short sleeves to 

(37) 



38 Surgeon's Apparel 

which are attached sleevelets. I prefer this style, because should these 
latter become blood-stained, as is frequently the case, they can be easily 
changed during an operation. I could never see the philosophy of wearing 
rubber gloves and having the arms exposed, a locality where the epidermis is 
prone to be scaly in spite of all the preparation that may be given to the 
part. I may add in a well-equipped hospital the rubber gauntlet extending 
from the wrist to the elbow is used, but these are expensive and not durable, 
so a gown with extra sleeves tucked into the glove is perfectly satisfactory. 
Gowns are prepared for sterilization by being laundered and incased in 
a folder or wrapper of muslin, then in another folder of the same material, 
the philosophy of these double wrappers will be appreciated when speaking 
of the technic of the operating-room. 

Surgeon's Suit and Shoes. — The majority of surgeons remove their street 
clothing and attire themselves in white duck suits and canvas shoes before 
assuming their gowns. This is esthetic, in good taste, and necessary from 
an aseptic standpoint. The operator must have high ideals of asepsis ; he 
should be the example of strict surgical cleanliness, towards whom his 
nurses should look for the latest and best thought, so that it behooves him 
to carry out every detail of a high standard. It is commonly urged that the 
spectators do not change their street apparel, simply covering the same with 
visitors' gowns, that they are capable of infecting the atmosphere of the 
operating-room. Inasmuch as they are remote from the field of operation, 
this source of infection is minimized. The surgeon's suit is sterilized at 
the same time as the gowns, and his shoes kept clean by the orderly of the 
institution. 

Caps. — Some head-covering is necessary for both surgeon and nurse 
during an operation : there probably is no dirtier field on the surface of the 
body than the scalp. When one considers at least 75 per cent, of people 
are afflicted with dandruff, to say nothing of dust and other extraneous 
matter finding lodgment in the hair, some form of protection becomes com- 
pulsory. Some hospitals have caps ready made for the surgeon, while other 
institutions utilize two thicknesses of 20 by 24-mesh gauze as a turban, which 
is far preferable, because the constant laundering of the cap prevents its 
accurate fitting, besides it would be necessary to have many sizes on hand 
to fit the different surgeons. What is true of the covering for the surgeon's 
head is even more applicable to the nurse, her hair being long and more 
difficult to cover. A cap similar to what is known as a "dusting-cap" with 
a drawstring makes an efficient covering, but here too the gauze turban is 
very satisfactory when properly applied. Nothing mars the refinement of 
technic in an operating-room more than to see loose strands of hair falling 
from under the nurse's cap. This is a common occurrence, and impresses 



Surgical Face-masks — Sponges 39 

the writer at once with the idea that if a nurse is careless to this extent 
during an operation where she is under observation, how far does her 
neglect extend in other lines of duty? Caps are prepared for sterilization 
by being folded in double wrappers together with the face-masks, if these 
are to be used. 

Face-masks. — Some surgeons use a covering for the entire face, with the 
exception of a large opening for the eyes. I can easily understand in case 
the surgeon has an acute tonsilitis or pharyngitis or is afflicted with ozena, 
the field of operation should be protected from the exhalations by some face 
covering. It is also appropriate for those operators who have growths of 
hair on their face to wear some form of protection. From a careful obser- 
vation I think I may say that the majority of surgeons do not use the mask. 
If such masks are utilized they are sterilized with the caps ; frequently, 
however, they are made by enveloping the face, with the exception of the 
eyes, with a 20 by 24-mesh 2-ply gauze. 

Nurses' Aprons. — These are made from the same material as the operat- 
ing-gowns, and are of the pattern commonly known as a "bib-apron," being 
suspended around the neck with a tape and a similar means for fastening 
around the waist. These are preserved in double wrappers and sterilized. 

Gauze Sponges for Use in the Operating-room. — It would be impossible 
to describe the various patterns of sponges used by different operators. 
Some are useless to the practical surgeon, while others are too complicated 
and consume too much time in construction. Whatever kind of sponge is 
decided on remember that no razv edges must be in evidence. They must 
be folded and invaginated so that when ready for use no raveling or fiber of 
the material will be apparent, because these little particles if left in the 
wound will prevent healing and at times occasion suppuration. Three sizes 
of sponges are generally used. 

Small or Wipe Sponge. — These are used exclusively for cleansing external 
wounds, and measure 3 by 5 inches when folded and ready for use. The 
following description will give you an adequate idea of how they are made : 
Take a piece of gauze approximately 10 by 17 inches having a selvage on 
one of the narrow ends, lay flat on the table, fold the selvage to within two 
inches of the opposite side ; then fold it in half ; take one end of the material 
and fold within two inches of its length ; again fold the piece in half ; you 
will then discover you have made a pocket which you will turn inside out, 
thus forming a second pocket, which is again treated by infolding. The 
sponge is prepared and all raw edges are within. It is better to use this 
kind of sponge for all newly made or fresh wounds than the ordinary cotton- 



40 Abdominal Sponges 

ball sponge, because of what I have stated, the liability of leaving some 
fibers in the wound to cause unpleasant results. These articles are pre- 
served in double wrappers and sterilized. 

Abdominal Sponge. — These are used exclusively in the abdomen. The 
average size when completed is 12 by 34 inches, and is made by cutting the 
gauze in yard lengths and folding one selvage one-third across the width of 
the material and lapping the other over this, thus we have the gauze folded 
lengthwise in three ply. Stitch across each end, in this way forming an 
oblong pocket; turn this inside out, making a second pocket; again invagi- 
nate this, and all raw edges will be concealed. I do not think it necessary 
to attach a tape to a corner of these sponges, as is done in some hospitals, 
to prevent their being left in the abdomen, because they are of sufficient 
size to be easily found. The tapes with hemostats attached are constantly 
interfering with the different manipulations that are taking place through 
the abdominal wound. Besides, if a careful method is instituted in counting, 
no sponges will be overlooked in the abdomen. When such an accident 
occurs you may rest assured it is due to a slipshod manner of preparing 
dressings in hospitals where there is no thorough method, or if rules have 
been established they have been modified or changed to suit the whims or 
fancies, or to lessen the duties of the nurse in charge. 

I have no patience with anyone who is careless, and if at any time the 
most thorough and careful attention to duty is needed, it is where human 
life is at stake. Nothing should be too laborious to preserve thoroughness 
of technic, nothing should be considered too trifling, if it adds one "jot or 
tittle" toward perfection. 

The large Abdominal Sponge or Towel, as it is termed, is made exactly 
like the above, only in three-yard lengths. They are not often used, except- 
ing in large pendulous abdomens, or where the bowel is very distended, in 
which cases they are more satisfactory to retain the intestines in the desired 
position than the smaller variety. The necessary number (generally three in 
a package) is prepared for sterilization in the same manner as the abdominal 
sponge, and is counted by the same method. 

I do not think it necessary to have any special size sponge for 
appendectomies, because if there is no suppuration and a small incision is 
made no sponges are needed, and if there is suppuration it is necessary to 
make a sufficiently large incision to facilitate the placing of sponges so as 
to wall off the field of infection previous to any manipulation ; in such cases 
the ordinary abdominal sponge answers admirably. 

Complications arise the moment the accessories are multiplied. This 
applies to sponges as well as to numerous and complicated instruments for 



Count of Sponges 41 

operating, and the surgeon or nurse who can accomplish thoroughly a given 
object with the simplest technic will have less chance for sepsis creeping in 
than those who use twice the number of supplies. 

Preliminary Count and Record of Sponges. — Having the sponges made 
of the required size, the necessary number (generally 14 in a package) is 
counted by the chief operating-room nurse, and re-counted by her assistant; 
they are then put in double wrappers; on the outside cover is stamped in 
indelible ink, "abdominal sponges/' followed by a number. A book is kept 
with the following data: package number, number of sponges, date sponges 
were sterilized and counted, and a blank space for the signatures of the head 
nurse and her assistant who are required to sign their names. Thus the 
sponges have been counted twice so far; by carefully following the routine 
these articles go through, you will discover they are counted six times before 
the abdomen is closed, and that too without the slightest extra work. 

I could mention several most deplorable accidents which have followed 
in the wake of the careless counting of sponges, and in order to impress on 
your minds the responsibilities which rest on you I will crave your per- 
mission to cite one case : One of the most brilliant physicians of Central 
Ohio developed appendicitis, and following out the Biblical adage that a 
"prophet is not without honor save in his own country," he traveled miles 
to obtain what he considered the greatest expert in the world to operate. 
After lingering weeks the patient died. The autopsy revealed a gauze sponge 
left in the abdomen ! The operation was performed at one of the best 
hospitals in the country, the surgeon was one with but few peers in his 
profession, — but as I have said, the strength of the most perfect technic 
lays in its weakest procedure. The carelessness of some one was responsible 
for robbing the profession of one of its most brilliant representatives. Can 
you realize now that the surgeon's reputation is more or less in his nurse's 
hands, and that the responsibilities resting on the nurse are so great that 
only those of the highest type of character should be permitted to enter our 
training-schools ? 

Dressings for Use in the Operating-room. — Plain Sterile Gauze Dress- 
ing, or as it is known in hospital vernacular, fluffy gauze. — The material 
is cut in twelve-inch squares, edges left raw, about 36 ply, which is a suffi- 
cient amount for an abdominal section or for any major operation. 

Cotton-gauze Dressings. — To make this combination, which is used in 
connection with the fluffy gauze, the ordinary absorbent cotton that comes 
in pound-rolls is cut crosswise in 12-inch strips, doubled on itself, and then 
covered with two-ply gauze; the gauze being sufficiently large to admit of 
the infolding and stitching of its edges. Two of these will cover the twelve- 
inch fluffy-gauze dressings. This combination makes a soft protective, is 



42 Medicated Gauze 

neat, and far preferable to the loose cotton laid on the gauze which is com- 
monly seen. These are preserved in double wrappers together with the plain 
dressings and sterilized the necessary length of time. 

Abdominal Outfit.— By this term is understood a package containing the 
necessary amount of fluffy gauze, cotton-gauze combination, together with 
an abdominal binder or Scnltetns bandage which will be described under the 
section devoted to "Bandages." This outfit is preserved in double wrappers 
and passes through the usual process of sterilization. 

Medicated Gauze. — I desire to call your attention to the two principle 
forms of medicated gauze, viz., Sublimate and Iodoform. 

Sublimate Gauze is simply the ordinary gauze soaked in. a solution of 
bichlorid of mercury of desired strength and then dried. It is not employed 
to the extent it was in former years. 

Iodoform Gauze is a sterile gauze saturated in a mixture of iodoform, 
ether, alcohol, and glycerin. The different pharmaceutical houses make this 
form of gauze very satisfactorily, so that you will be rarely called upon to 
make it. The disagreeable odor produced during its preparation permeates 
everywhere; however, some large hospitals prefer to manufacture it. Under 
such circumstances it can be made as follows, bearing in mind every step 
must be thoroughly aseptic, because when prepared it should not be sterilized : 

(1) The gauze is cut in one-yard strips and carefully sterilized in the 
autoclave in the same manner as other dressings. 

(2) The nurse cleanses her hands, adjusts cap, gown, and two pairs of 
rubber gloves as though she were preparing for a celiotomy. 

(3) Sterilize the following articles: 1 basin, 1 spatula, and 1 pair of 
dressing forceps. 

(4) Have the following ingredients at hand — 

Iodoform Powder § 6 

Glycerin . . .pt. 1 

Alcohol I 8 

Ether § 8 — Haubold. 

(5) Carefully mix the iodoform and glycerin into a smooth paste with the 
spatula, add the alcohol and finally the ether. 

(6) Remove the double wrappers from the sterile gauze and discard the 
outer pair of gloves. 

(7) Emerse only as much gauze as will be thoroughly permeated with 
the mixture. 

(8) Fold a single layer of the gauze to a convenient size and preserve 
in small sterile glass jars, capable of being hermetically sealed. I prefer this 



Tape or Gauze Packing 



43 



material kept in amounts sufficient for one dressing, instead of having large 
quantities stored in one container and removed therefrom as occasion de- 
mands, as in this zvay contaminaton is invited. 

The plan of keeping this gauze in sterile towels and oiled silk as advised 
by some authors is impracticable, because the odor permeates all other 
dressings with which it is stored. Under such circumstances the plain gauze 
is as odoriferous as the medicated article. 




Illustration III 

Tape or Gauze Packing-. — Note the raw edges are not 
in evidence, and the size of the container. 



Tape or Gauze Packing. — This is made from a piece of gauze three inches 
wide and two yards long, so folded that no raw edges are apparent. To 
accomplish this infold the raw edges towards the center of the entire strip, 
then fold the same on itself and you have four-ply gauze about three-fourths 
of an inch wide. (See illustrations III and IV.) This is made from either 
plain or iodoform gauze ; if from the former, it is placed in heavy-glass test 



44 



Oiled Silk, Rubber Dam, Etc. 



tubes, the mouths of which are closed with cotton over which is tied a two- 
ply piece of 20 by 24 gauze ; these are then placed in the autoclave with the 
other dressings for sterilization. If made from iodoform gauze the strictest 
aseptic precautions must be taken, as this material should not be sterilized 
by heat, in spite of whatever may be said to the contrary. It is best kept in 
similar sterile glass containers as recommended for the plain-gauze tape. 




Illustration IV 

Tape or Gauze Packing- preserved in test tubes an< 
for sterilization. 



ready 



For all ordinary cases such a package will contain a sufficient amount of 
either dressing. 

Oiled Silk, Rubber Dam, Gutta-percha Tissue. — These materials are used 
to protect the dressings in the case of suppurative wounds, gall-bladder 
operations, etc., or where it is necessary to maintain a moisture within the 
dressings, as in skin grafting. They are kept in stock in their original 
packages ; when needed a suitable piece is selected, thoroughly washed in 



Gloves and Their Care 45 

soap and water, rinsed, and placed in mercuric solution 1 :2000 for not less 
than ten minutes; before being used they are again rinsed. 

Gloves. — After having passed through the gantlet of criticism and with- 
stood the most bitter arguments that any surgical accessory has ever met, 
these useful articles are now a fixed part in the technic of a modern surgeon 
and nurse. They are as much of a necessity as the anesthetic, the scalpel, 
or the scissors, and the surgeon or nurse who omits their use is derelict in 
duty. Experiments have shown that with the usual methods of hand ster- 
ilization, less than three per cent, are sterile. Reference has already been 
made to the necessity of wearing gloves when doing dressings. Gloves are 




Illustration V 

Sterile Gloves, wrist folded outward, powdered, and preserved in sterile towel. Note 
the care exercised by having- the hands gloved during- the preparation. 



essential also in vaginal and rectal examinations. It is hardly necessary to 
mention the fact that they come in various sizes, so that it behooves the 
operating-room superintendent to be acquainted with the different numbers 
necessary to fit the surgeons, assistants, and nurses. Too small a glove de- 
stroys the tactile touch by excessive pressure, and one too large interferes 
with dexterity. 

Care of gloves after being used. — 

(1) Wash thoroughly inside and out with soap and water. 

(2) Balloon with air to ascertain if damaged by needle punctures, etc. 

(3) Discard all imperfect gloves. 

(4) Sterilize by one of the following methods : 



46 Adjustment of Gloves 

Sterilization of Gloves — Method One. — 

(a) Boil for five minutes. 

(b) With sterile-gloved hands place the gloves between sterile tozvels 

and thoroughly dry inside and out. 

(c) Assort and powder, inside and out, with sterile talcum powder. 

(d) Fold the wrist of the glove outward, thus forming a cuff; this 

is highly important to facilitate the adjustment to the hands 
later. 

(e) Preserve by separating each pair in a fold of a sterile towel. 

(f) Thus a roll is formed, each fold containing one pair of gloves. 

(g) The ends of the roll are folded toward the center' and pinned. 

An outside wrapper is then applied. (See illustration V.) 

Method Two.— 

(a) Dry thoroughly inside and out after carefully cleansing. 

(b) Assort and powder inside and out. 

(c) Fold the wrist of the glove outward to form a cuff. 

(d) Separate each glove from its fellow by a two-ply layer of gauze. 

(e) Preserve in folds of a towel in the manner described in method 

one. 

(f) Place in the autoclave and sterilize with the dressings, etc., for 

five to eight minutes. 

Both of these methods are efficient. The process of boiling as described 
in the first method should be employed when infection has been encountered 
during an operation. The weakest link in this method is the liability of 
contamination in the final steps. The second method is sufficiently thorough 
for all practical purposes when infection has not been present. It possesses 
the advantage in that the gloves are not handled after being sterilized. In 
both methods the gloves are dry when needed for use — a great step in 
advance in glove sterilization. 

Adjustment of gloves to the hands. — 

(1) Powder the hands thoroughly with sterilized talcum powder. 

(2) Grasp the cuff of the glove, insert the fingers and pull into place. 

The ease with which this is accomplished will surprise those unac- 
quainted with this method. 

(3) After both gloves are adjusted, turn back the cuff, — in this way the 

outside of the glove has not been touched by an ungloved hand. 
The hands of the surgeon and nurses are kept dry all through an 
operation. (See illustration VI.) 



Adtustment of Gloves 



47 



Method Three. — 

(a) Envelop the gloves in a towel. 

(b) Boil with the instruments at the time of the operation for five 

minutes. 




Illustration VI 

Manner of adjusting- gloves. Observe the outside of the glove 
is not touched when the adjustment is made as has been 
described. 



When prepared in this manner it is necessary to fill the glove with water 
before it can be adjusted — this process keeps the hands moist throughout 
the operation and produces a maceration of the skin similar to that seen on 



48 Operating-room Accessories 

the hands of a laundress. Again, the naked hand is frequently used to 
assist in the adjustment of the first glove and hence may deposit some in- 
fectious material on it. 

Talcum Powder. — This homogeneous powder is mentioned in connection 
with rubber gloves because it facilitates their adjustment when used dry. It 
is kept in cans with perforated tops and extra lids, or in small glass jars 
covered with two-play 20 by 14-mesh gauze, so that it can be easily dusted 
without opening the container. It is sterilized for the usual length of time 
in the autoclave with the dressings. 

Towels. — An ample supply of these should be kept in stock and ready for 
use at a moment's notice. They are made from a good grade of bleached 
toweling, cut in one-yard lengths and laundered before being used. Those 
intended for the operating-room are placed in double wrappers, twenty-four 
to a bundle, and sterilized. 

Operating-table Pads. — Because of the objectionable symptoms which 
arise when a patient is caused to lie on a hard cold surface for any length 
of time, it is necessary to cover the top of the operating-table with suitable 
pads. These are composed of cotton wadding incased in muslin and quilted. 
Before being used on the table they are enveloped in a rubber cover and 
then in a sterile muslin slip. This latter is removed after each operation, 
laundered, and sterilized. 

Blankets. — There are various ways of keeping the patient warm during 
an operation. In some hospitals they prepare what is known as a chest 
protector. It is made similar to an ordinary "pneumonia cotton jacket," 
only in a more substantial manner, so it can be used repeatedly. I much 
prefer two small blankets, one to cover the thorax, and the other the lower 
extremities. These are more easily removed after an operation than any 
other cover, besides if a chest protector is employed it will still be necessary 
to use a blanket for the limbs. These blankets need not be sterilized after 
being laundered inasmuch as they are carefully covered by rubber sheeting, 
sterile towels, and celiotomy or other sheet. 

Rubber Sheets.— Several of these must be kept in stock. They are used 
to protect the blankets and keep the patient dry. They are especially neces- 
sary with those operators who use a double preparation. (See lectures on 
"Preparation of Patient for Operation" and "Operating-room Technic") 
These rubber sheets are kept sterile by being thoroughly scrubbed in soap and 
water, rinsed, and immersed in bichlorid of mercury solution 1 :2000 and 
dried. 

Celiotomy Sheets. — These are designed from a good quality of muslin 
sheeting, two-and-one-half yards square, with an oval aperture 9 by 6 
inches, so placed as to correspond with the field of operation. This acces- 



Ligatures and Sutures 49 

sory makes a nice covering for the blankets, etc., with which the patient is 
surrounded during an operation, as well as for the table which it practically 
conceals. These are kept in double wrappers and pass through the usual 
process of steam sterilization. 

Ward-service Dressing Outfit. — Double-wrapped packages containing the 
following articles are sterilized and kept in stock for use in the ward: 

(1) 1 dozen cotton-ball sponges. 

(2) 12-ply fluffy gauze. (The usual 12 by 12 inches.) 
(3)4 towels. 

This combination is simple and contains all that is necessary for an 
ordinary plain dressing. 

Ligatures and Sutures. — A Ligature is some means employed for tying, 
while a Suture as applied to surgery is some material used for stitching. 

The materials used for sutures and ligatures may be divided into two 
classes, (1) the absorbable, and (2) nonabsorbable. Among the former 
can be mentioned catgut and kangaroo tendon, while among the latter may 
be classified silk, pagenstecher or celluloid linen, silkw T orm gut, horsehair, 
and wire. You will note from this that all animal sutures are not neces- 
sarily absorbable. A perfect suture or ligature should have the following 
qualities : 

(1) Nonirritating to the tissues. 

(2) Be capable of sterilization, being made antiseptic, and retaining this 
latter quality until absorbed. 

(3) Of sufficient tensile strength to accomplish the purpose for which it 
is used. 

(4) Pliable so that it can be easily handled, securely tied, and remain so. 

(5) Absorbable so that it can be buried in the tissues and not have to be 
removed. 

(6) Durable, so that its longevity will be sufficient to accomplish the 
purpose for which it was intended. 

Catgut. — This material seems to fulfill all of these purposes better than 
any other. No one seems to know from whence the name originated, and 
as that is of no practical value I shall omit the different opinions that have 
been advanced. It is obtained from the connective tissue of the sheep's 
intestines, preferably from the European animal, as the quality of this gut 
seems to be of a higher standard. 

It is peculiar that even at the present time there is a controversy as to 
what part of the intestine is really employed in the manufacture of the 
surgical article. Dr. W. S. Halsted of Johns Hopkins University, Balti- 



50 



Sterilization of Catgut 



r>> 



more, I think maintains that the submucous layer (connective tissue) is 
the one which is utilized. Dr. A. D. Whiting of Philadelphia, in a series of 
microscopical examinations confirms this statement and concludes thus : 
"Every strip that I examined was prepared by this method [a method spoken 
of in his article] and every one showed the same structure, viz., a fibrous 
reticulum, probably the connective tissue of the intestine." To this latter 
physician I am indebted for many useful suggestions that will be found in 
this connection. 

There is one fact that should always be borne in mind in the preparation 
of this material for surgical use: "catgut is dead animal tissue, therefore a 
good culture-medium for microorganisms ;" hence it must not only be steril- 
ized, but made antiseptic. If only sterilized, it forms an excellent propa- 

gating-bed when in contact with bacteria; to 
obviate this it should be rendered antiseptic as 
well, and retain this property during the process 
of its absorption. 

Sterilisation of Catgut. — There are numerous 
ways advocated for its sterilization, so numerous 
indeed that one is convinced of the imperfec- 
tions of all; whenever there is a multiplicity of 
remedies for a given disease you can rest as- 
sured the results obtained are not what is 
desired, and so it is with the sterilization of this 
article. Some hospitals prepare catgut from the 
crude material, others buy it in hermetically 
sealed tubes ready for use. 

I am fully convinced that the manufacturers 
are furnishing a product which is as good as any 
that can be had at the present time ; and in indi- 
vidual containers, it is preferable to the home- 
made article. There are three varieties on the 
market, the plain, chromicized, and iodized. The 
plain will remain in the tissues from seven to ten 
days before being absorbed, while the chromi- 
cized has a life history of twenty to thirty days, 

the longevity of which depends on the length of time the gut is soaked in a 

solution of bichromate of potash. Both varieties come in the standard sizes, 

namely, 00, 0, 1, 2, and 3. (See illustration VII.) 

With the kind permission of Dr. Willard Bartlett (the originator) of St. 

Louis, Missouri, I append the simplest and at the same time the most perfect 



< 



.1 !W 

i 



Illustration VII 

A Tube of Catgut. 
The proper con- 
tainer in which 
to purchase this 
material. 



Sterilization of Catgut 51 

routine that has been brought to my attention for the sterilization of catgut 
in iodin : 

"(1) The strands are cut into convenient lengths, say thirty inches, and 
made into little coils about as large as a silver quarter. These coils in any 
desired number are then strung like beads onto a thread so that the whole 
quantity can be conveniently handled by simply grasping the thread. 

"(2) The string of catgut coils is dried by hot air for four successive 
hours at the following temperatures, 160 F., 200 F., and 220 F., the changes 
in temperature being gradually accomplished, care being taken that the catgut 
does not touch metal or glass. 

"(3) The catgut is placed in liquid albolene, where it is allowed to remain 
until perfectly 'clear,' in the sense that the term is used in the preparation 
of histological specimens. This is usually accomplished in a few hours, 
though it is my custom to allow the gut to remain in the oil over night. 

"(4) The vessel containing the oil is placed upon a sand bath and the 
temperature raised during one hour to 320° F., which temperature is main- 
tained for a second hour. 

"(5) By seizing the thread with a sterile forcep the catgut is lifted out 
of the oil and placed in a mixture of iodin crystals one part, Columbian 
spirits (deodorized methyl alcohol) one hundred parts. In this fluid it is 
stored permanently, and is ready for use in twenty-four hours ; the thread 
is then cut and withdrawn. 

"It seems to me important that the gut should be thoroughly 'cleared' 
before the oil is heated, in order that we may be thus certain that the tem- 
perature of the center of the strand becomes as high as that of the oil 
outside. It may be noted further that I do not remove the oil from the 
gut before placing it in the storing solution. This is done purposely, since 
catgut which is perfectly free from oil, is so very sensitive to the action of 
water that it readily untwists and becomes tangled after it is used in a 
wound but a few moments. This storing fluid simply takes off enough oil 
from the exterior of the strand so that it is not too slippery for use, and the 
albolene being a bland, non-irritating substance, there is no reason why it 
cannot be safely left in the gut. The iodin rapidly permeates the strand; 
the same will be found stained black after a few hours, and consequently the 
surgeon will have the assurance that he is introducing an antiseptic as well 
as a thoroughly sterile suture material." 

You will note in the above procedure that the temperature is brought to 
320° F., which is far above any temperature necessary to destroy bacteria. 
It is made antiseptic by being submerged in a i-per cent, iodin-alcohol 
solution. The author names some of the best surgeons of the country as 
being advocates of his method. I have gone somewhat fully into the details 



52 Ligatures and Sutures 

connected with this material, because it stands out as the favorite American 
suture and ligature, being used in this country to a greater extent than 
elsewhere. 

Kangaroo Tendon is obtained from the Australian animal bearing that 
name ; it practically has been displaced by chromicized catgut. It is occasion- 
ally used in holding the fragments of a fractured bone together. 

Silk. — This material is being less used daily for several reasons: (1) It 
absorbs tissue fluids into its meshes and thus becomes a favorite culture-bed 
for bacteria; (2) being nonabsorbable it sooner or later becomes an irri- 
tant and therefore should never be used in buried tissues. Its field of use- 
fulness was formerly in intestinal work, but it has been supplanted by 
pagenstecher. Silk is sterilized by being boiled. Some operators then sub- 
merge it in 1 :2000 mercuric solution, the object of the last step being to 
add an antiseptic quality to the material. It comes in various sizes (00 to 
10, catgut gauge), and in two forms, white and iron dyed, — the latter being 
black makes it more visible for removal. 

Pagenstecher is linen thread coated with celluloid. — This coating forms 
practically an impervious protection and at once overcomes some of the 
objections to silk. Its tensile strength, too, is greater, so that a much finer 
thread can be used, — another commendable feature, especially in intestinal 
work. It is sterilized by being boiled. 

Silkworm Gut. — To obtain this the worm is killed just about the time it 
is to spin its cocoon. It possesses high tensile strength, and is practically 
impervious to moisture. It varies somewhat in size. Some surgeons use it 
exclusive to all other material for closing incisions of the skin, while others 
on account of its impermeability employ it in vaginal operations. It is easily 
sterilized by being boiled with the instruments at the time of operation. 

Horsehair, as the name implies, is obtained from the tail of that animal. 
This material has long been used by the profession for sutures. There was 
a period in which it fell into disuse to a great extent, but within the last few 
years it is again occupying a prominent position in certain classes of work. 
It is impermeable to moisture, the strands are very fine, can be armed with 
small needles, and are of fairly high tensile strength, more easily tied and 
more pliable than silkworm gut, hence you can appreciate the excellent 
purpose it serves in cosmetic surgery of the face and mouth. It comes in 
hanks of about one hundred strands and is sterilized by boiling, after being 
thoroughly washed in soap and water. 

Wire. — There are three varieties of wire used, — annealed iron, silver, and 
gold. I have mentioned them in the order of their usefulness. Their 



Methods of Drainage . 53 

sphere is very limited, being at the present time used chiefly to approximate 
fragments of bone. To do this the wire must have a fairly good tensile 
strength and be sufficiently flexible to be twisted without breaking, all of 
which properties the iron wire possesses to a greater extent than the softer 
metals. I may add that annealed wire, as demonstrated by the radio- 
graph, when used in bone surgery is occasionally absorbed, which certainly 
would not be the case with the other two. Sterilize by boiling. 

Drains. — In the last few years drainage has simplified itself so that the 
complex mechanisms that were formerly used have been entirely abandoned. 
The facts are, very few drains accomplish the purpose for which they are 
made. The various forms of glass drainage tubes are a matter of history 
among modern surgeons. At the present time, the cigarette drain, the 
Mikulicz drain or tampon as it should be termed, and rubber tubes of dif- 
ferent calibers are utilized. 

The cigarette drain is made by rolling an open-mesh gauze (14 by 20) 
into a loose wick and covering the same with rubber dam or gutta-percha 
tissue, leaving the gauze projecting at both ends. The length of this drain 
will depend upon the depth of the cavity in which it is to be used. They are 
generally prepared in twelve-inch lengths, packed in test-tubes properly 
stoppered and sterilized. Before being used they should be moistened in 
sterile water to hasten capillary attraction. Theoretically iodoform gauze 
should not be made into a cigarette drain, inasmuch as the drug fills the 
meshes of the gauze and is supposed to prevent capillary attraction; how- 
ever, this medicated gauze is frequently used in this way. 

The Mikulicz tampon is used chiefly as an intra-abdominal compress, where 
there is persistent oozing of blood, or where large areas of necrotic tissues 
are left. The tampon is made by invaginating a sufficiently large square of 
iodoform gauze through the abdominal wound so as to permit its distal 
extremity to protrude through the incision, thus forming a pouch, which is 
then filled with plain sterile gauze to produce the necessary compression. 
Thus there is a sufficient amount of iodoform to act as an antiseptic and 
retard bacterial growth and yet not enough to produce deleterious effects 
by excessive absorption, while the sterile gauze acts as the compressing 
agent. These tampons are not kept in stock, but are constructed by the 
surgeon as needed. 

The Rubber Drainage Tube is made from the best para rubber. Several 
sizes should be kept on hand to meet the necessities of the individual case. 
To prepare them for use the proximal extremity is cut wedge shape and 
the sides of the tube fenestrated so as to allow a free exit for fluids. They 
are used chiefly in gall-bladder operations and in amputations of the 



54 ' Roller Bandages 

extremities. An assortment of these articles should be kept sterilized and 
preserved in sterile glycerin in glass containers to be ready for use when 
needed. 

Bandages — Roller. — These are made from various materials, but those 
manufactured from 40 by 44-mesh gauze have so far superseded muslin and 
other fabrics, that I shall call your attention principally to this variety. 
They are made in different widths, from one to four inches, and generally 
ten yards long. 

It is poor economy and far from practical to take the time of a nurse 
to roll gauze bandages, because they can be purchased in any size from the 
manufacturers, sealed in paper covers, and are sufficiently sterile for all 
practical purposes, inasmuch as they do not come in contact with the field 
of operation and are only handled by the surgeon and nurse after the 
operation is completed and the dressings are in place. Muslin should no 
longer be recognized as a proper material from which to make roller 
bandages ; it is not as flexible, nor as pliable as gauze, does not conform to 
the parts with the same facility as the lighter material, and keeps the part 
warmer than the more open-mesh substitute. However, at times a small 
amount of elasticity is desired in a roller bandage. In such cases they are 
made from flannel of the desired width and length. The field of usefulness 
for such a bandage is in cases of phlebitis, especially of the lower extremi- 
ties, where the object is to produce a slight elastic compression on the veins 
and utilize evaporating lotions, which would not be possible if a rubber 
bandage were adjusted. In varicose veins, however, such a bandage is not 
to be compared with the elastic stocking. 

I do not propose to give you the various ways and diagrams, which have 
been handed down as heirlooms, on bandaging. The application of a band- 
age is an art which is acquired only by practice ; in fact, at the present time 
the average surgeon follows no classic rules or patterns in applying band- 
ages, his single thought and whole purpose being to have the dressings kept 
in place by the simplest method, without causing any irregular or undue 
compression. 

For convenience in describing a bandage it will be divided into "the initial 
end, which is within the roll, the body or rolled part, and the terminal 
end!' — DaCosta. 

General Rules for the Application of a Roller Bandage. — In applying 
a bandage, place the outer surface of the terminal end on the part and work 
upwards, making an equal tension on each turn. Frequently in adjusting 
a bandage you will notice the turn or lap does not conform snugly to the 
contour of the part; to overcome this, make what is known as the reverse 
by holding the roller in the right hand, start the bandage obliquely upward, 



Scultetus Bandage 55 

place the index finger of the left hand at the point which will correspond to 
where the new turn is about to begin, keeping the roll very slack, fold the 
bandage downward from the point of the index finger, encircle the part, 
and then increase the tension; this may seem simple but it will require prac- 
tice to accomplish it dexterously. 

When approaching an articulation a figure-of-eight turn should be used, 
which may be described as follows : Beginning on the outside of the mem- 
ber and below the joint pass upward and inward to a point well above the 
joint; carry the bandage underneath the member to a point external to and 
above the articulation, thence over the anterior surface to a location internal 
and below the joint, pass beneath the member to the point externally from 
which the "figure-of-eight" was begun ; repeat these various steps covering 
two-thirds of the previous turn of the bandage until the joint is completely 
incased. 

As a rule the amateur uses too wide a bandage. Bandages for the finger 
should not be over an inch wide, for the hand and arm two inches ; the same 
is applicable practically to the lower extremities, the toes requiring about an 
inch bandage, the foot and leg a two-inch roller, while the thigh will pos- 
sibly demand one of three inches in width. 

A Scultetus Bandage, also known as an abdominal binder or many-tailed 
bandage, is usually made by taking a piece of cotton flannel twelve inches 
square and stitching across it strips three and one-half inches wide by thirty- 
six to forty-eight inches long in such a manner that each piece overlaps the 
succeeding one about half its breadth, shingle-fashion so to speak — leaving 
free ends on either side. All edges must be hemmed to prevent raveling. 
Two or three different sizes should be kept always on hand. This is a very 
useful bandage, being not only applicable after abdominal operations, but in 
surgical procedures on the thorax such as amputations of the breast, etc. I 
may add that instead of using the ordinary canton-flannel abdominal binder 
after celiotomies, when ether or chloroform has been the anesthetic or 
where vomiting is liable to occur, I employ an extemporized binder made 
as follows : 

(1) Cut from a roll of adhesive plaster twelve inches wide a portion suffi- 
ciently long to encircle the abdomen and allow a lap of four to six inches. 

(2) Place the plaster evenly under the patient. 

(3) Remove the crinoline protective from each end to a point that cor- 
responds to the width of the patient's back. 

(4) Cut each end into four equal strips. 

(5) Apply each strip by overlapping alternately over the abdomen in the 
same manner as any other many-tailed bandage. 



56 



Extemporized Abdominal Binder 



Advantages of this Bandage. — 

(1) It acts as a splint to the traumatized abdominal wall. 

(2) It gives firm support in postoperative vomiting, or coughing, the 
result of bronchitis or pneumonia. 

(3) It retains its position and prevents the patient from interfering with 
the dressings below. 

In this connection I cannot refrain from mentioning a case of gangrenous 
appendicitis on which I operated. The subject was a lad of nineteen. The 
operation was performed about noon; near midnight of the same day, the 




Illustration VIII 

A simple retaining Abdominal Binder. Useful and practical for re- 
taining- abdominal dressings. Note the open-mesh webbing on 
either side of the lace, also the adhesive straps on either side of 
the webbing which hold the bandage in place. The crinoline pro- 
tective is partly removed from the adhesive on the left side. 



patient got out of bed, obtained his clothes from the wardrobe, and watching 
an opportune moment clandestinely left the hospital, walking three miles 
before reaching home. His recovery was uneventful and complete. I 
hardly think he would have been able to have accomplished this feat had the 
ordinary abdominal binder been used. He has since passed the rigid exam- 
ination for the United States Navy. 

I do not claim originality for this form of bandage, nor do I recall ever 
having read of it, or seen others use it. If another originated the idea, I 



Plaster-of-Paris Bandages 57 

beg to express my regrets for not having my attention called to it. For a 
very practical bandage see illustration VIII. 

The T Bandage. — This is made as a rule from cotton flannel, and consists 
of two parts : a girdle of sufficient width to afford comfort, and a perineal 
strip three and one-half to four inches wide and one yard long, which is 
attached to the center of the girdle posteriorly. It is used to retain dressings 
after operations on the rectum, perineum, and vagina; as can be easily un- 
derstood the perineal strip is passed between the thighs and pinned to the 
girdle in front. These bandages are generally sterilized in the same pack- 
age with the dressings for vaginal and perineal operations. 

Plaster-of-Paris Bandages. — Bandages impregnated with plaster-of-Paris 
as a means to immobilize joints, and as a substitute for wood and metal 
splints in the treatment of fractures is a product of American ingenuity, and 
was first brought to the notice of the profession by Professor Lewis Albert 
Sayre of New York, one of the early but noted orthopedic surgeons of the 
country. These bandages are made from crinoline or gauze of the desired 
width and length, then infiltrated with plaster-of-Paris (what is known as 
dental plaster is much preferred for this purpose). After being rolled, they 
are placed in air-tight containers, as any moisture deteriorates their value. 
Here again it is a waste of time and energy for hospitals to prepare this 
kind of bandage, as the manufacturers supply a very good grade, sealed in 
individual tin boxes, with full directions for use. In applying such a band- 
age to an extremity — 

(1) Shave and thoroughly cleanse the part. 

(2) Carefully incase the member in ordinary cotton wadding held in 
place with a gauze bandage. 

(3) Immerse the plaster-of-Paris roll in a basin of water until all bub- 
bles cease to rise, which indicates the water has thoroughly permeated it. 

(4) Remove and gently squeeze out superfluous water. 

(5) Apply to the part by making spiral or circular turns, smoothing out 
any irregularities with the hand. The "reverse turn" should never be made 
because of the extra tension this causes. A nice finish is given the cast by 
making a creamy paste of the plaster and rubbing the same over the surface. 
The number of layers necessary will vary with the size and muscular devel- 
opment of the part. An increased rigidity or stiffness can be obtained by 
reinforcements of tin or other thin metals placed between the layers of the 
bandage. The removal of a cast is easily accomplished by first moistening 
the same with hydrogen dioxid or vinegar, which softens the plaster suffi- 
ciently to permit of its being cut with a strong, sharp knife. A similar pro- 



58 Adhesive Plaster 

cedure is resorted to when it is necessary to cut a fenester, or window, in a 
cast in order to dress an injured portion of the limb, as in compound frac- 
tures or resections of bone. 

Another method of making a plaster-of-Paris cast which is often used in 
injuries about the shoulder is — 

(1) Form a pattern out of paper and lay the same on the table. 

(2) Moisten the plaster roll in the same manner as above. 

(3) Pass the same backward and forward over the pattern, care being 
taken to have each layer nicely adjusted and smooth; the number of layers 
will depend on the muscularity of the part. 

(4) Apply and mold in place. 

(5) When hardened, a few turns of gauze bandage will retain it in posi- 
tion. I cannot leave this subject without warning you of the dangers con- 
nected with using a plaster-of-Paris bandage in acute sprains or very recent 
fractures, in fact wherever swelling is liable to ensue, because the unyielding 
cast may so compress the blood-vessels as to produce gangrene, examples of 
which have been brought to my notice. The nurse therefore should be on 
the alert for any swelling that may occur after the adjustment of a plaster- 
of-Paris bandage. 

Silicate-of-Soda Bandages. — The solution of silicate of soda as found on 
the market for making bandages is a varnishlike fluid, containing about 20 
per cent, of silica and 10 per cent, of carbonate of soda. Bandages made 
from this solution are used when a lighter cast is needed than one made of 
plaster of Paris. It makes a clean retaining splint, is easily applied, but is 
not durable, and requires a longer time to harden; nevertheless for smaller 
joints or for light splints it answers admirably. To apply such a cast — 

(1) Cleanse and shave the part. 

(2) Surround the same with cotton wadding. 

(3) Apply the ordinary gauze roller bandage. 

(4) Varnish each successive layer with the soda solution. 

(5) Repeat steps three and four until a sufficient thickness is obtained. 
To remove this cast moisten with warm water and cut with a strong, 

sharp knife. 

Adhesive Plaster. — This is a useful article in the surgeon's armamenta- 
rium. It can be obtained in rolls twelve inches wide and ten feet long, 
which is the most economical way to buy it for hospital use; various 
widths of this material may be purchased on spools. The kind known as 
zinc oxid is far preferable, being less irritating to the skin. Before applying 



Normal Saline Solution 59 

it to the surface of the body the part should be carefully shaved to permit 
of its adhering more firmly as well as to lessen the pain when removed. All 
adhesive plaster is impermeable to fluids, hence in applying this material to 
a wound or other abraided surface, some protection should be given the in- 
jury in the way of sterile dressings beneath the plaster. The various ways 
in which this material is utilized will be explained in the different technics. 

Physiologic Saline or Normal Salt Solution. — This is a solution of table 
salt (sodium chlorid) in water, and is an evolutionary product of necessity. 




Illustration Villa 
Flasks of Normal Saline Solution 



Experience has demonstrated that if plain sterile water is injected into the 
blood-current disintegrative changes occur in the corpuscles and fatal re- 
sults ensue; or if thrown into the rectum the epithelium becomes swollen 
and absorption is exceedingly limited, hence the necessity of obtaining a 
fluid that could be substituted for plain water which would be bland, 
isotonic, and which would not have the deleterious effects I have mentioned. 
After numerous experiments chlorid of sodium in the proportion of 0.6 per 
cent, or 0.7 per cent, with water was demonstrated to fill the requirements of 
such a fluid, although more complicated solutions have been recommended ; 



60 Normal Saline Solution 

occasionally oxygen gas is forced through the normal saline solution in order 
to saturate it before it is employed in intravenous infusions. Distilled water 
is preferable to ordinary drinking water for making this solution. 

Directions for Preparing 1 quart of 0.6-per cent, solution. (Approxi- 
mate. ) 

(1) In a clean flask place Chlorid of Sodium grs. 90 

Distilled Water qt. 1 

(2) Stopper the flask with absorbent cotton and boil for ten minutes. 

(3) Filter through cotton and again boil for a similar period. 

(4) Preserve in the flask in which the solution was last boiled. 

(5) Tightly stopper the flask with sterile cotton, over which is adjusted 
two or three thicknesses of sterile gauze held in place by a small bandage. 

This solution will not keep indefinitely. Several flasks of the prepared 
solution should be constantly on hand in the sterilizing room. 

Field of Usefulness. — After severe hemorrhage, following the effects of 
shock, as an irrigating fluid in non-infected wounds, and as a medium for 
nutritive enamata normal salt solution becomes one of the most useful adju- 
vants in surgery. (The methods of its employment are given in lecture 
devoted to "Transfusion — Infusion.") Having some characteristics of 
the blood serum it should not be used as an irrigating fluid in infected 
wounds or cavities, unless followed by sterile water, because it forms a 
fertile medium for the propagation of bacteria. I think this is a settled 
question. 

BIBLIOGRAPHY. 
Preparatory and After-treatment in Operative Cases — H. A. Hau- 

BOLD, M. D. 

Modern Surgery — J. C. DaCosta, M. D. 

A Simplified Heat Method of Sterilising and Storing Catgut — Willard 
Bartlett, A. M., M. D., St. Louis, Mo. 

The Ideal Ligature — A. D. Whiting, M. D., Philadelphia, Pa. 



LECTURE VI 

WARD SERVICE— HISTORY- RECORD OF THE PATIENT 

The thorough equipment of the operating-room and the careful technic 
which has been maintained can go for naught unless each floor of the hos- 
pital is proportionately furnished with necessary requirements to carry out 
the scheme of asepsis. Every floor should have a large room equipped with 
the following: 

(1) A water sterilizer, for hot and cold sterile water, connected with a 
porcelain sink. (See illustration IX.) 

(2) A sterilizer for basins, pitchers, etc., heated by either gas or steam, 
or an immersion trough for the same purpose. I do not think much of this 
latter, because one never knows the length of time the basins have been 
immersed; however, it is more economical. (See illustration X and XL) 

(3) An instrument sterilizer, heated by steam from the boiler-room or 
gas. (See illustration XII.) 

(4) An aseptic stand with four metal shelves, on which are kept the 
more common drugs used in surgery; the different stock solutions, basins, 
pitchers, graduates, glass receptacles for catheters, irrigators and the usual 
glass or rubber nozzles which are used with these, hand brushes, etc. - 

(5) An aseptic table with metal top. This is a very necessary piece of 
furniture. Besides the ordinary advantages of such a table, it serves as a 
stand for the gas stove or "hot plate" as it is termed, which is used in warm- 
ing solutions and sterilizing the small instruments employed on the floor. 

(6) A cupboard similar to the one used in the sterilizing -room, in which 
are stored the sterile dressings, sponges, bandages, adhesive plaster, and the 
instruments belonging to the floor. In a compartment of this cupboard 
(which is always kept locked and in charge of the head nurse of the floor) 
is also stored a complete infusion outfit, as follows : 

Infusion Outfit. — 

(a) Two flasks of sterilized saline solution. 

(b) A complete suspension reservoir. (For description see lecture on 

"Transfusion — Infusion.") 

(61) 



62 



Ward Service 




Illustration IX 

A Water Sterilizer. One reservoir containing - hot and the 
other cold sterile water. 



(c) Instruments 



(d) Other Articles 



2 infusion needles (dull and sharp pointed). 
1 sharp scalpel. 

1 pair of scissors. 

3 or 4 small hemostats. 

1 pair of dissecting forceps. 

2 curved needles. 

r Number 1 catgut in original tube. 
Cocain tablets, hypodermic syringe, 1 small 

graduate for local anesthesia if necessary. 
1 bottle solution adrenalin chlorid. 
1 ward dressing outfit. 
1 two-inch roller bandage. 
Gloves. 
1 bath thermometer. 



Sickroom Memoranda 63 

The instruments and such articles as can be are sterilized with the utmost 
care and preserved (with the exception of course of the flasks) in double 
wrappers. One of the most annoying circumstances is to have a patient 
suffering from shock or hemorrhage, needing an infusion and having to wait 



Illustration X 
A Steam Sterilizer for Basins and Pitchers 



an indefinite period until the various articles are collected from the different 
floors. 

Clinical Charts and Sickroom Memoranda. — On every floor of a hos- 
pital there should be provided a desk, conveniently located, at which the head 
nurse presides. Besides the ordinary drawers in which are kept clinical 
charts, history forms, reception slips, requisition blanks, etc., there should be 



64 



Sickroom Memoranda 



provided a system of oblong pigeon-holes numbered to correspond with the 
rooms or beds on the floor, in which are kept the clinical chart, sickroom 
memoranda, and the reports from the clinical and pathological laboratories, 
all attached to a "chart holder or file." (See section "Blank Forms" in this 
lecture.) This is the place of election for charts that are in service and not 
hung at the head of the bed; in this latter location they are scrutinized by 
visitors and the patients themselves. A slight rise in temperature, as 
recorded, is at once noted by the patient ; if it happens to be a neurasthenic 




Illustration XI 

An Immersion Trough which is filled with a solu- 
tion of 1 : 1000 bichlorid of mercury in which 
basins, pitchers, etc., are immersed in order to 
sterilize them. 



woman, she immediately becomes worse; or if a patient who has a sup- 
posed grievance against the institution or surgeon, daily memoranda are 
clandestinely made in the hopes that they will aid in a lawsuit later. 

The keeping of a clinical chart and sickroom memoranda is an art which 
should be developed, the nurse should practice "printing" by hand in 
preference to writing the different notations. There are varieties of 
clinical charts and sickroom memoranda on the market, and every hospital 



Sickroom Memoranda 65 

has its own with some variations ; yet it is not the kind of chart that is 
used, but the kind of information recorded that interests the surgeon. For 
instance, what practical deductions can be made when looking under the 
column for "urine" is seen "1"? This means nothing; no valuable infor- 
mation has been gained. What the surgeon needs to know is the amount 
of each urination, preferably expressed in cubic centimeters. If any 
abnormalities are present they should be mentioned under "Remarks" ; the 
same is true of the excreta from the bowel, the estimated amount, color, 
consistency, and other peculiarities carefully recorded; — this is particularly 
necessary in accident cases. 

The patient's temperature, pulse, and respiration should be taken and 
noted as soon after admittance as possible, not only as a matter of form, 
but because later reference to the condition at that time may be important. 
It is a rule to record these valuable signs four times daily, viz., at eight, 
twelve, four, and eight o'clock, and more frequently if the necessities of the 
case demand it. Immediately after a major operation the pulse should be 
counted every half hour and charted, together with any change in its 
character. The temperature should also receive frequent attention at this 
time and notations made. (See lecture on "Principles and Practice of 
Postoperative Nursing.") 

// the case be an emergency, the most painstaking memoranda should be 
made ; the pulse counted, its character set forth ; the temperature taken, if 
subnormal emphasized to call attention to the same; the respiration re- 
corded, whether shallow, deep, or stertorous ; the condition of the pupils, 
whether responding to light, their size, or disparity if any is present; the 
color of the face ; the condition of the extremities ; note whether hemor- 
rhage is present and record the same; as well as wounds if any are in 
evidence. The object being to give a perfect picture of the case immediately 
on admission. Later if a criminal or civil lawsuit is the outcome of the 
injury, it is accepted as prima facie evidence, and gives a "square deal" to 
both parties. The details of the operation, if one is made, are recorded in 
the history of the case. 

// the patient is one for operation the surgeon in charge generally notifies 
the surgical intern of any special examinations he desires, such as blood, 
stomach contents, stools, etc., together with his orders for preparation and 
the day and hour the operation is scheduled. The house-surgeon writes such 
orders and signs his name. 

The examination of the urine is considered a necessity before and after 
an operation, and no orders are needed to that effect. (See lectures on 



66 Sickroom Memoranda 

the "Preparation of Patient for Operation'' and "Principles and Practice 
of Postoperative Nursing/') 

The daily memoranda should also set forth the condition of the patient's 
appetite and the amount of nourishment taken. I look on this as one of 
the true indices of a patient's convalescence. Cases giving every indication 
of recuperation, such as the return of the pulse, temperature, and respira- 
tion to normal, whose excreta give no evidence of abnormalities, but whose 
appetite has not returned and to whom food is repugnant, must be looked on 
with suspicion ; something unforeseen is developing, hence this important 
item should be carefully recorded. 

The chart should indicate what drugs have been given and the time of 
administration. This is especially true of morphin and other anodynes; 
as two important indications are gathered from this information, either 
the patient is in pain or has developed a habitus, which is not uncommon 
in chronic cases. 

The amount of stimulation, if any is given, must be charted; this 
includes rectal seepage, infusion of salines, etc. 

The number of hours the patient slept is worthy of notation. 

After a wound has been dressed the nurse should record the condition 
of such wound, the kind of dressings used, the surgeon, assistant, or nurse 
who made the dressing, note the character of the discharge if any, and 
whether the same is increasing or decreasing. 

The hour of the day a patient is taken to the operating-room should be 
recorded, as well as the time of return. 

After an operation where drainage has been used, or vaginal or uterine 
packing employed, the surgical intern or assistant should make a notation 
to that effect on the patient's chart and sign his name, because if the 
vagina or uterus has been packed the patient should be catheterized ; it also 
serves to remind the surgeon and nurse of the same so that it may be 
removed at the proper time, and not permit the patient to discover it 
herself weeks after. The same is true of drainage, — it is occasionally for- 
gotten (unless charted) until a chill with an increased temperature directs 
attention to the wound, when the cause is discovered. After these "neces- 
sary evils" are removed they should be recorded, together with the name 
of the surgeon or nurse who did it. The nurse is not responsible for 
accidents similar to the above, if a notation is not made on the chart after 
the operation. 

It is the nurse's prerogative, one of the few she possesses, to demand 
that the surgeon write his daily orders in full for each patient, either on 



History-record of Patient 67 

the daily memorandum-sheet, or in an order-book which is kept for that 
purpose. At the close of each day a short synopsis is recorded as follows : 

(a) The highest temperature, pulse, and respiration. 

(b) The lowest temperature, pulse, and respiration. 

(c) The amount of urine excreted. 

(d) Number of defecations. 

(e) The amount of anodyne administered, if any. 

(f) Condition of appetite. 

Extraordinary symptoms, or conditions that require emphasis, should be 
printed in red ink in the column reserved for "Remarks." The clinical 
chart should be compiled from the daily memoranda. It is not considered 
the nurse's duty to take the history of the patient. If the case is a private 
one, the surgeon's assistant performs this task, and if a charity one it is the 
duty of the surgical intern to compile it. 

Blank Forms. — Sickroom-memoranda forms, clinical charts, anesthetic 
slips, and clinical and pathological-report blanks have become practically 
standardized and may be purchased of any well-equipped surgical supply- 
house. 

History-record of the Patient — Compiling the History of the Patient. — 
In all well-equipped hospitals a history is kept of each patient. Some of 
these history-forms are very extensive, giving the minutest details; others 
are simplified, touching only the salient points of the individual case, yet 
sufficiently explicit to permit correct deductions to be made from an analysis 
of a given number of records — which really is the end in view. They also 
serve as a protection for the conscientious surgeon from those vicious 
productions of the "ambulance chaser," — the malpractice suit. Nothing re- 
flects any more discreditably on a hospital than to see poorly kept history- 
records. I think without any exaggeration I may say that a correct conclu- 
sion can be made as to how a hospital is managed by glancing through the 
manner and method in which the history-records are kept. If care is taken 
in the compiling of these important articles, rest assured the institution is 
under the supervision of one who is striving to maintain its efficiency in all 
of the various departments. 

All surgeons and hospitals have their own ideas as to the necessary data 
which should be recorded, the nurse therefore would hardly ever be required 
to formulate a history- form ; an occasion may arise however when she may 
be called on to suggest a suitable blank-form for history-records in which 
case the following will assist as a working basis. It is applicable to both 
general-surgical and gynecological cases : 



68 



History-record of Patient 



HISTORY OF PATIENT. 

Date 



Service of Dr 

Diagnosis 

Case No Name_ 



.Referred by Dr. 



Age Sex. 



.Social Relation. 



Complains of the following 



Address^ 



Occupation. 



.Race- 



Family History 



Previous History 



Present History in order of development 



Physical examination— (Abnormalities only are recorded) 



Date and character of operation 



Details of operation 



Postoperative Complications and Treatment 



Result 



Discharged from the Hospital 
Subsequent History 



History compiled by Dr. 



N. B. This history is not to be filed until the clinical chart, anesthetic slip, 
and the clinical and pathological reports are attached. 



History-record 



69 



Compiling the History-record. — The compilation of a patient's history 
is an art which some never acquire, while others seem to be able to grasp 
the important items in any case, group them in sequence, and express the 
facts tersely in a few words. While brevity should be the aim, it should 
not be carried to such an extent as to curtail the important points and omit 
the essence of the history. Two questions have always arisen in hospital 




Illustration XII 
A Steam Sterilizer for Instruments 



practice regarding the compilation of the patient's history: (1) Is it 
proper and ethical to place on record the confidential and important state- 
ments made by the patient to the surgeon? (2) Who shall compile such 
histories, the surgical intern, or the surgeon's private assistant? The latter 
question can be easily settled by the surgeon. The private assistant is 
better qualified for this purpose. As to the propriety of placing a private 



70 



Filing History-records 



patient's history on record in a public hospital there may be some room 
for argument, but certainly there should be no serious controversy, because 
during the operation the surgical intern and the nurses witness the character 
of the operation and but for their ethical obligation could easily reveal the 
nature of the case. The same is true of the pathologist: the examination 
of the specimens submitted to him at once indicate the character of the 
disease with which the patient is afflicted, but his sense of moral duty 
is sufficient restriction to prevent a breach of trust. The typist, stenographer, 
or secretary who keeps the records after they are filed is as much bound 
by ethical obligations to preserve secrecy as the stenographer in the surgeon's 
office who writes his private letters. In fact in Ohio and some other states 
it is a criminal offense for a stenographer or secretary to reveal information 
obtained in his or her line of duty. The records should be kept with the 
same secrecy as the private letters and other business transactions of the 
hospital. Carefully compiled history-records are as large an asset as an 
institution can possess. 

Filing the History-records. — At the present time filing-cabinets consisting 
of a section for each letter of the alphabet can be purchased for this pur- 
pose; these sections may be subdivided into the five vowels to facilitate 
finding the individual record. To illustrate: suppose the patient's name is 
Jones, the record should be filed in the section "J," subdivision "O," because 
"J" is the first letter in the surname and "O" the first vowel occurring in 
the name. This cabinet index must be used in connection with a counter 
index, which may be either an ordinary book index, or a card-system. The 
card or page of the book should contain the following data : 



CLASS OF OPERATION 


DATE 


NAME OF PATIENT 


SURGEON 


RESULT 









































































To illustrate the use of this counter index, suppose the surgeon desires 
to ascertain the number of appendectomies he has made during a given 
period and the results following a certain line of treatment. The clerk 
of the hospital can immediately refer to the counter index under the letter 



Filing History-records 71 

"A" and give the number of such operations, the names of the patients, the 
dates of the operations, and the results. Should the surgeon require minute 
information on one or all of the cases the clerk refers back to the chief 
index and obtains the history-record of each patient. To be concise the 
chief index classifies the history-record under the name of the patient and 
the counter index classifies the character of the operation. One cannot be 
successfully used without the other. 



LECTURE VII 

PREPARATION AND STERILIZATION OF SURGEON'S AND 

NURSES' HANDS 

It must be borne in mind that there are certain locations in the skin 
where bacteria normally exist, viz., under the epidermis, in the shafts of the 
hair- follicles, and the ducts of the sudoriferous (sweat) and sebaceous (oil) 
glands. 

You can therefore easily understand that efforts at skin sterilization 
must be so applied as to remove all dead epidermis from the surface; in 
addition such measures must be used as will have a tendency to dilate the 
mouths of the sweat and oil glands and increase their excretions, in the 
hope that such bacteria as are present may be eliminated. This latter 
thought can hardly be considered theoretical, inasmuch as actual experience 
demonstrates that while the excretions from these glands may show bacterial 
growths after surgical cleansing of the hands and immediately before an 
operation, these cultures get less and less as the glands pour out their 
excretions during operative procedures because the increased perspiration 
and oily excretion dilute the bacteria more and more, until eventually they 
are minimized. Perfect skin sterilization is not known. Efforts along this 
line have their limitations, — all that can be accomplished is to reduce the 
number of bacteria, and to hold in check their virulence. 

Before hand sterilization is begun it is necessary for the surgeon to 
change his street clothes and assume his operating-suit, shoes, and head- 
gear (cap or turban). The nurse likewise changes her uniform and sub- 
stitutes an operating-gown, and covers her hair according to the hospital 
method. 

After the hands have been sterilized according to the methods to be 
described, the surgeon assumes his gown and adjusts sleevelets and gloves, 
while the nurse covers her gown with the nurses' bib-apron, and adjusts 
gloves and sleevelets. (See illustration XIII.) 

Basic Principles — Mechanical Cleansing. — (1) Trim the finger-nails 
reasonably close. 

(2) Immerse the hands for a minute or two in warm water. This softens 
the dead epidermis under which bacteria are prevalent, and assists in dilat- 

(72) 



Mechanical Cleansing 



73 



i 






/ 




ing the mouths of the sweat and oil glands as well as increasing their 
excretions, thus forcing to the surface the underlying and hidden bacteria. 

(3) With a fairly stiff brush, soap, and 

water, methodically scrub every portion of x~-w 

the hands and arms for five minutes, paying / } 

special attention to the nails, inner side and Mztm^r 

back of the forearms. Cleanse the under sur- v4 ^ 

face of the nails with a sharp orange stick or kK, 

nail file, the former being preferable. 

(4) Again revert to the scrubbing process 
for another period of five minutes. During 
this procedure the hands, arms, and brush 
have frequently been rinsed under the run- 
ning water, and the soap as repeatedly ap- 
plied, so that the same dirty mixture is not 
continuously used over the surface. 

(5) Rinse with sterile water and use what- 
ever antiseptics meet the approval of the 
surgeon. 

It is a frequent occurrence to see the most 
expensive "medicated" soaps purchased by in- 
stitutions for use in this connection, and at 
the same time see brushes employed that have 
long passed their stage of usefulness. I do 
not think any special kind of soap has any 
specific value; preference, however, may be 
given to sterilized green soap, because of the 
large amount of caustic potash which it con- 
tains, but when this cannot be obtained, as in 
private practice, the ordinary domestic laun- 
dry soap is equally efficacious. I do not use a 
basin in hand sterilization in the hospital, 
relying on running sterile water; in private 
practice this will not be possible. 

This mechanical cleansing of the hands and forearms is common to all 
methods, and is more important than all the chemical antiseptics which may 
be used. If a step is omitted in hand sterilization allow it to be any 
except the mechanical scrubbing with soap and brush with frequent changes 
of copious volumes of warm sterile water. Germicides and antiseptic solu- 
tions quiet and calm the conscience of the surgeon and nurse, but mechan- 



Illustration XIII 

surgical nurse in complete 
uniform. Note the manner in 
which hair is covered. Ob- 
serve the bib-apron which 
has been assumed after the 
hands have been cleaned. 



74 Mechanical Cleansing 

ical and methodical scrubbing as I have described is the important step in our 
present knowledge of removing infectious material from the hands, as well 
as the field of operation. From this point variations occur — 

Method One. — 

(1) Mechanically cleanse. 

(2) Take equal portions of chlorid of lime and carbonate of soda; add 

enough water to make a paste, apply freely to the hands and arms. 
This mixture eliminates chlorin gas, which imparts a warmth to 
the skin. When this has subsided, 

(3) Remove the same with sterile water. 

(4) Immerse the hands and arms in a solution of corrosive sublimate 

(1:2000). 

(5) Rinse the members with alcohol. 

(6) Dry with sterile towel. 

This method was first suggested by Weir of New York and has the 
support of a large number of surgeons. Its chief disadvantage is, that if 
used frequently it produces an acute eczema. 

Method Two. — 

(1) Mechanical cleansing. 

(2) Hands and arms thoroughly dried and rubbed with a sterile towel. 

(3) Then scrubbed with gauze saturated in alcohol (94 per cent.). 

(4) Again dried with sterile towel. 

Method Three. — 

This is the method I have employed for some years, with results as per- 
fect as any I know. 

(1) Mechanical sterilization. 

(2) Immerse hands and arms in a basin of Harrington's solution for 

one-half minute. 

(3) Neutralize with alcohol. 

(4) Dry and rub with sterile towel. 

This method will also irritate some hands, but no more than other 
methods ; my confidence in Harrington's solution gives it preference to other 
antiseptics. 



LECTURE VIII 

PREPARATION OF PATIENT FOR OPERATION 

Formerly all patients who were to undergo a major operation were sub- 
jected to days, and in many cases weeks, of preparatory treatment, which 
consisted chiefly of drastic purgatives and so-called tonics. In those days 
the profession did not individualize as carefully as at present; the strong 
and robust, the weak and debilitated, the nervous and lymphatic patient, all 
received the same routine. The surgeon overlooked the fact that the 
neurasthenic patient was being rendered more incapable of undergoing the 
ordeal from the psychic effects of anticipation and the hospital environ- 
ments, while the strong and robust deprived of their usual liberty were 
being reduced unnecessarily. It is true nothing was known of what is now 
termed "resisting power;" blood examinations had not yet been brought 
to the attention of the profession ; antisepsis was in its infancy, and every- 
thing gave place to it. 

For the sake of description I think I can divide operative cases into 
three classes — 

(1) Those with acute fulminating infections, those with ruptured ectopic 
pregnancies, and subjects for Cesarean sections, — to be exact, emergency 
cases, where systematic preparatory treatment is out of the question. 

(2) Those acute or subacute cases in which the general health has not 
been depreciated and time is not a factor, as in the former class; such 
cases do not require over twenty-four or forty-eight hours' preparatory 
treatment at the most. 

(3) The patients that belong to this division are those whose health has 
been undermined by chronic diseases and long standing infections. The 
majority of this class are poor hard-working people who depend on their 
own efforts for a livelihood; these require rest and hygienic attention to 
bring their powers of resistance to as high a point as possible before 
operative measures are instituted. 

With the exception of the first or emergency class, in which time is the 
important element, there are certain principles that must be followed out. 

As a rule the following preparations begin twenty-four hours previous 
to the time appointed for operating. The patient should be put to bed 

(75) 



76 



Preparatory Treatment 



and given a thorough sponge bath, after the bedding has been protected 
by rubber sheeting. This is done not only for cleanliness, but also to 
remove such debris as has accumulated on the skin, and which prevents that 
organ from functionating to its fullest capacity, for as you will recall in 
your lectures on physiology, the skin acts as a supplementary organ to the 
kidneys in the elimination of toxic materials from the body; therefore 
in giving the bath be as thorough as the condition of the patient will permit. 




teflffl 




^ 




Illustration XIV 
An ordinary Dressing- Car. — Note the waste receptacle for soiled dressing's, etc. 



You will note that I have specifically mentioned a general sponge bath, 
because the bathtubs in the average hospital are filthy, laden with patho- 
genic germs, and actually infect the surfaces we are striving to cleanse. 
The basins employed must be sterilized by boiling, as these innocent-looking 
receptacles are commonly used in the cleansing of purulent wounds, and 
hence may become a source of infection. A clean nightgown is then put 
on the patient; if a woman, her hair is braided and securely tied, and 
finally the nails are manicured. Nothing jars the sensibilities quite as much 



Preliminary Duties 



77 



as to see dirty finger-nails; especially is this true of the surgeon, nurse, or 
patient. These steps may be termed the "esthetic toilet," but in reality they 
are more than that. The patient may now be allowed to rest for some 
hours before beginning the surgical toilet. Only such a nurse as has had 
lectures on surgical nursing, bacteriology, asepsis, etc., should be selected 
to prepare the field of operation, because she appreciates the dangers of 
infection and the difficult task of skin preparation. In my opinion a rule 
should be established in every hospital that this task be assigned the senior 
nurse of the floor. In some hospitals one of the operating-room nurses is 
assigned the task of the preliminary preparation of the field of operation. 
This is quite appropriate, inasmuch as such a nurse realizes the necessity of 
thorough work and scrupulous care. 

Preliminary Duties. — A ward dressing car should be equipped with 
such articles as will be necessary in the preparation of the patient. These, 
of course, will vary according to rules established by individual surgeons 
for this purpose. The same basic principles of asepsis, however, must 
obtain. (See illustration XIV.) 



Equipment of Ward Dressing Car. — 

(1) 2 sterile basins. 

(2) 2 large flasks or pitchers, filled with warm sterile water 

(3) 1 soft sterile brush and green soap. 

(4) Such antiseptics as are used by the individual 

surgeon. 

(5) 1 package of sterile towels. 

(6) 1 package of wipe sponges. 

(7) 1 package of cotton-gauze dressings and abdom- 

inal binder, if the field of operation is the 
trunk, or suitable dressings and bandages for 
other portions of the body. 

(8) 1 safety razor or depilatory powder. 

(9) 1 Kelly pad, 1 rubber sheet, both carefully 

cleansed. (See illustration XV.) 

(10) 1 bowl boracic-acid solution (4 per cent.) for 

cleansing the meatus urethrae prior to cathe- 
terization. 

(11) 1 sterile glass female catheter. 

(12) 1 sterile bottle for specimen of urine. 

(13) 1 sterile bib-apron for nurse, after mechanical 

cleansing of the patient has been accom- 
plished. 

(14) Such other articles as may suggest themselves for the individual 

case. 




Illustration XV 

A Kelly Pad — A 
useful article, 
but one difficult 
to keep sterile. 



78 Primary Preparation of Field 

Nurse's Preparation. — This has been deferred until after the preparation 
of the ward car because of the danger of contaminating the clothing while 
preparing the outfit. Carry out the following schedule: 

(1) Roll the sleeves of the hospital uniform well above the elbow. 

(2) Cover the hair with cap or turban. This is obligatory. 

(3) Assume sterile gown. 

(4) Mechanically sterilize hands and arms for the usual ten minutes. 
(See lecture on the "Preparation and Sterilization of Surgeon's and 
Nurses' Hands.") 

(5) Complete sterilization of hands with such chemical antiseptics as 
meet the individual surgeon's views. 

(6) Adjust two pairs sterile rubber gloves. 

The car is now removed to the patient's bedroom and the following steps 
carried out, which are known as 

The Primary Preparation of the Field of Operation. — (1) Remove the 
outer wrapper from the dressings, towels, etc., so as to prevent contamina- 
tion of the hands later on. 

(2) Protect bedclothing by use of rubber sheet. 

(3) Inflate Kelly pad and place the same at the edge of the bed, provision 
being made for proper drainage. 

(4) Move patient to the edge of the bed in such a position that the field 
to be cleansed will correspond with the pad. 

(5) Arrange nightgown so that it does not interfere with manipulations 
by protecting the garment with towels. 

(6) Shave thoroughly the field of operation; using as you will the 
modern safety razor, there will be no danger of the unsightly scars that 
are commonly seen. Some surgeons prefer a depilatory paste which is 
made as follows, according to the formula and instructions of Dr. N. C. 
Morse of Iowa: 

Crystallized sodium sulfid 3 3 

Unslaked lime (fresh) 3 10 

Pulverized starch 3 11 

These ingredients are reduced to a powder separately, then mixed and 
kept in a hermetically closed bottle. A sufficient amount of this is mixed 
with water into a paste, applied generously for four or five minutes ; 
the parts are then washed. 

(7) Begin mechanical sterilization with soap, water, and brush, using 
mild friction; rinse repeatedly during the usual period of ten minutes, not 



Primary Preparation of Field 79 

only to cleanse the surface of the skin of its loose epidermis, but that the 
friction and warm solutions may excite the excretions of the sweat and 
oil glands of the skin and thus bring to the surface such bacteria as are 
hidden in the recesses of the sudoriferous and sebaceous glands. Especial 
care will be taken to extend such manipulations over a larger surface than 
is necessary and paying attention to the different flexures of the body, the 
umbilicus, and the folds of fat in the obese. 

(8) Wash the field thoroughly and copiously with sterile water, dilution 
is the desideratum. From this point on asepsis must govern each step. 

(9) Remove outside pair of gloves and assume bib-apron. 

(10) Adjust towels around the field of operation so as to protect every- 
thing that is not sterile. 

(11) Use such antiseptics as meet the views of the individual surgeon 
and follow by copious rinsing with sterile water so as to remove all irritating 
antiseptics, finally dry the field. I prefer Harrington's solution (subse- 
quently neutralized with alcohol) for the following reasons : 

(a) The formula contains alcohol, which aids in the removal of the 

saponified fats and oils of the skin and thus cleanses the 
mouths of the oil and sweat glands more thoroughly. 

(b) Experience has demonstrated this solution to be more efficient 

than any other. 

(c) The odor is pleasant as compared with the different mixtures of 

iodin and benzin or ether which some surgeons employ. 

(12) Apply cotton-gauze dressings held in place by a well-fitting abdom- 
inal binder and instruct the patient under no circumstances to disturb or 
infect the field by contamination with the hands. 

I desire to give you the philosophy for the use of ether, benzin (gasolin), 
or alcohol, after the mechanical sterilisation has been accomplished. All 
three of these drugs are excellent solvents for fats, hence they are employed 
to remove such oily matter as remains on the surface of the skin and in 
the mouths of the sudoriferous and sebaceous glands. Benzin is being used 
by some surgeons medicated with iodin in the proportion of 1 per cent, for 
the preliminary cleansing of the field of operation, while a stronger solution 
(5 per cent.) is utilized on this area just before operating. This product 
of petroleum has no advantage over ether or alcohol except from the stand- 
point of economy, which is more than offset by its objectionable and 
lasting odor. 

Whatever antiseptics are employed you will note that the toilet of the 
patient when complete is perfectly dry, which is preferable from the stand- 
point of comfort, besides being more scientific than the moist dressings of 



80 Preparation of Special Locations 

former days. Keen's Surgery remarks on this topic: "He (the patient) 
is allowed to pass the night without the discomfort of a wet antiseptic 
dressing. These dressings are not only a source of discomfort and 
annoyance, but they irritate the skin, contributing, if anything, against a 
sterile field." 

The Soap Poultice which was formerly used is made of equal parts of 
green soap and glycerin, in which is immersed a gauze towel that is applied 
to the field of operation after it has been prepared, and allowed to remain 
in place for twelve or fifteen hours. It is only mentioned to be condemned, 
because it macerates the tissues, develops greater fertility of the skin, and 
frequently produces dermatitis. 

Obtaining a Specimen of Urine. — After the field of operation has received 
the primary preparation, it will be the nurse's duty to obtain a specimen 
of urine. In female patients a catheter should be used. This is the 
appropriate time for catheterization because the nurse is properly gowned, 
her hands sterilized and gloved, and the necessary articles are at hand to 
perform the same (being part of the equipment of the ward car). 

(1) Sterilize the urethra and adjacent tissues with the warm saturated 
boracic-acid solution. 

(2) Protect the surrounding area with sterile towels. 

(3) Lubricate the catheter and introduce into the bladder, preserving 
the urine in the sterile bottle which has been prepared for the same. 

Catheterization is necessary in women patients, otherwise the specimen 
of urine intended for analysis becomes mixed with the vaginal excretions 
and does not give a true conception of its contents. The bottle is labeled 
with the name of the patient, number of room or ward, and date, and sent 
to the clinical laboratory, the analysis of which is attached to the patient's 
clinical chart, together with such other reports of examinations as have 
been ordered, as blood- counting, analysis of stomach contents, etc. 

The examination of the urine is one of the essentials' in the preparation 
of the patient for operation. 

Modifications in the Preparation of Special Locations— H<?ad — In 

major operations on the cranium the entire scalp should be shaved. The 
average specialist does not require this in operations on the mastoid, simply 
demanding a generous field, unless there is suspicion of thrombosis of the 
lateral sinus, in which case the general rule prevails, — shave the entire scalp. 
When complete depilation is ordered it facilitates the sterilization, but in 
cases where only a local area is to be shaved, the remainder of the hair and 
underlying scalp have to be made as aseptic as possible, — a most difficult 



Preparation of Special Locations 81 

task. In the former case, the general rules as to the preparation of the 
field are carried out, and in addition, the scalp painted with tincture of 
iodin previous to applying the protective dressing. While in the latter, after 
(the local area has been shaved, the hair is shampooed thoroughly, repeatedly 
rinsed with sterile water, then with alcohol or ether to remove all soap and 
oleaginous material, and finally with mercuric solution 1 :2000, and dried ; 
the local area is then painted with iodin and the protective dressings applied. 
Or Harrington's solution may be employed after the rinsing with sterile 
water, in which case it is neutralized with alcohol, dried, the field of 
operation painted with tincture of iodin, and the usual protective dressings 
made. 

Mouth. — Here the high degree of immunity that exists precludes the 
necessity for any elaborate preparation. Like other muco-cutaneous cavi- 
ties it is impossible to carry out the usual methods of surgical cleansing, 
nevertheless it is your duty to endeavor to produce as aseptic a condition 
as possible by having the patient use an alkaline antiseptic mouth wash 
with a tooth brush every three or four hours the day before the anticipated 
operation, and once or twice the morning of the same day. This procedure 
seems imperative, not only in surgery of the mouth, but also in operations 
on the stomach as shown by recent investigations. Furthermore it should 
be a rule that mouth cleansing be considered one of the essential steps in 
the preparation of the patient who is to be given a general anesthetic, as 
undoubtedly pneumonia has been caused by neglect of this. (See lecture 
"Anesthesia — Anesthetics," section "Preparation of the Patient.") 

Stomach. — This organ in a healthy individual is amicrobic (free from 
bacteria). In cases of pyloric obstruction the result of gastric ulcer 
or cancer the stomach is unable to completely empty itself of its contents 
and the residual food goes through a process of putrefaction with its 
accompanying bacterial growths. It is chiefly for these conditions, in which 
a complete evacuation of the stomach does not occur, that surgical pro- 
cedures are instituted. Hence when preparing a patient for an operation 
on this organ liquid nourishment should be administered to facilitate the 
stomach emptying itself, followed in three or four hours by lavage to 
remove any residue of food. Nourishment must never be administered later 
than six hours before operation. Thorough lavaging, sterile dietary, and 
cleansing of the mouth, as has already been mentioned, will produce a suf- 
ficiently aseptic condition for surgical purposes. An analysis of the stomach 
contents and an examination of the feces is frequently desired by the 



82 Preparation of Special Locations 

surgeon in these cases — the report of which should be attached to the 
patient's clinical chart, thus adding important items to the history-record. 

Face. — The general rules as to preparation prevail. Attention must be 
paid to the hair, scalp, and mouth as these are the chief sources of infection 
following operations in this region. 

Thorax. — No especial rules are necessary in the preparation of this field, 
but great care however must be given the axilla, with -its superabundance 
of sweat and oil glands and hair follicles, — a fertile field for bacteria. The 
flexure of the breast on the chest wall should receive close attention, and 
if any eczema be observed the same should be brought to the surgeon's 
notice at once, as he may desire to postpone the operation until the same is 
healed, or use some extra precaution locally for a day or two, previous to 
surgical interference. Fatal infections from an insignificant dermatitis in 
the field of operation are on record. 

Rectum. — The majority of surgeons make no attempt at sterilizing this 
organ previous to operation. In fact it would appear superfluous and yet 
those who make this field a specialty assert that better results are obtained 
when attention is paid to the toilet of the rectum than when no attempt 
is made along these lines. The day previous to operation injections of a solu- 
tion of hydrogen dioxid (25 per cent.) are administered morning and 
night, which simply act as solvents for any concretions that have accumu- 
lated in the pockets and rugae with which this organ abounds. These 
solutions are expelled. Enemata of warm boracic-acid solution (2 per 
cent.) are then given, and allowed to be retained as long as possible. 

The Vagina. — Inasmuch as this organ is frequently the site for surgical 
operations, and the results so dependent on its thorough sterilization, I deem 
it necessary to lay stress on the following steps looking toward the primary 
cleansing of this canal : 

(1) Place the patient athwart the bed on a Kelly pad with the usual 
provision made for drainage of the cleansing solutions. 

(2) Shave the parts or use depilatory powder, and cleanse the surround- 
ing cutaneous surfaces. 

(3) With a small, soft sterile brush, soap, and water carefully scrub the 
vaginal canal, frequently lavage with sterile water. 

(4) Irrigate with carbolic acid (2 per cent.) or lysol (2 per cent.) 

(5) Apply a cotton-gauze dressing held in place by a "T" bandage. 

(6) After evacuations of the bowel or bladder, cleanse the cutaneous sur- 
faces with one of the above antiseptic solutions. Dry and reapply bandage. 

Bladder. — This organ should receive careful attention prior to operative 
procedures by being thoroughly lavaged two or three times the day previous 



Preparatory Diet 83 

to operation, either with solutions of permanganate of potash, argyrol, or 
boracic acid and an irrigation of one of these drugs just before the time set 
for operation. A sterility of the urine is supposed to be accomplished by 
the administration of hexamethylenamin (urotropin), 5 grains, every three 
hours. In cases where the urethra is much stenosed (strictured) it may be 
impossible to irrigate this viscus, under which conditions the internal med- 
ication I have mentioned must be relied on. 

Hands and Feet. — These deserve as careful attention as any portion of 
the body about to be operated on : the hands are constantly exposed to infec- 
tion, while the feet are a fertile field for bacteria. Some of the most severe 
infections following minor operations on the hands and feet that have come 
under my notice have been the result of careless preparation. The usual 
rules as laid down must be carefully carried out, with special attention given 
the nails and flexures between and under the digits. 

Further Necessary Preparation — Diet. — The menu of a patient about 
to be operated should be regulated for twenty-four hours previous to such 
an ordeal, but not restricted to a point bordering on starvation, the powers 
of resistance must be conserved, and not reduced. To accomplish this the 
diet list should consist of easily digested articles of high nutritive value, 
which will leave as small a residue in the bowel as possible and not cause 
gaseous formations. The usual extracts of beef as found on the market for 
making bouillon and the various meat broths as served in hospitals are abso- 
lutely worthless from the standpoint of nutrition : they contain the flavoring 
extracts of the meat and possibly are pleasing to some tastes. I take advan- 
tage of this latter quality and make them a vehicle for the administration of 
egg albumen, thus obtaining a bouillon or broth with a definite value. The 
usual manner of serving egg albumen, viz., whipping the white of egg and 
adding it to lemonade or broth, which makes a murky looking mixture, is 
not conducive to tempting an appetite. A more desirable way is to whip the 
whites of several eggs to a "stiff froth," as expressed in the vernacular of 
the cuisine, which is then put in the refrigerator for an hour or two ; when 
needed the froth is removed and a clear liquid is left. A definite amount of 
this is added to the desired vehicle, probably a half ounce to a glass of orange 
or lemonade, or a similar amount to a cup of bouillon. 

I do not use milk in any form as an article of diet immediately before and 
after abdominal operations, and in advising against it I think I express the 
views of most operators ; however it is your place as nurses to obey orders, 
not give them, yet the best nurse is the one who in the absence of definite 
instructions can fill an emergency, and you will be on the safe side if you 
omit milk as an article of diet in abdominal cases unless otherwise advised. 
My reason for not using this food is, it is seldom thoroughly digested as the 



84 Drinking Water 

common occurrence of curds in the stools of patients demonstrate ; these 
undigested particles form a most excellent culture-medium for the colon- 
bacillus; hence it is one of the greatest factors in the production of flatus, 
which latter is the surgeon's bete noire during manipulations in the abdomen, 
and after surgical interference it adds great discomfort to the patient. On 
the other hand when the abdominal cavity is not the field for operative at- 
tack and the digestive system is in a normal condition, milk is an important 
article in the dietary of the patient; its diuretic qualities are not to be 
underestimated, while the many ways it can be utilized render it a factor 
in feeding the surgically sick. The following diet, I think, will suit the 
average surgeon: 

MENU. 

Breakfast — Orange or grapefruit; oatmeal with cream; soft-boiled eggs; 
bacon, toast, coffee or tea with cream. 

Dinner — Bouillon prepared with egg albumen, medium cooked roast beef, 
toast, baked apple, coffee or tea with cream. Fruit is permissible if the 
patient desires it. 

Supper — Bouillon (albumcnized) , baked fish or broiled oysters or chicken, 
toast, coffee or tea with cream. Oatmeal is well indicated. 

If the operation be other than a celiotomy I would add milk and the 
various custards to the above. In this list I have not seriously interfered 
with the usual meals of the patient, but at the same time have omitted such 
articles as would contribute to digestive disturbances. On retiring for the 
night a cup of albumenized bouillon or albumen lemonade may be given, 
especially in debilitated patients. 

Drinking Water. — I have advisedly left the subject of water for special 
consideration because of its importance. To appreciate the necessity of 
giving a patient about to be operated plenty of this fluid a day or two pre- 
vious, one must remember that the kidneys are the great excretory organs 
of the economy, that the largest amount of body-waste is eliminated through 
them ; that when these waste products are not excreted they form toxic prin- 
ciples which tend to break down "body-resistance," — the very factor to be 
conserved. It must be borne in mind the kidneys can be stimulated to in- 
creased activity by drinking large amounts of bland fluids and they can be 
lavaged, so to speak, in the same manner. I think of no step in the prepara- 
tion of the patient more often neglected and which is so necessary. 

When one considers the fearful thirst that is a sequence to celiotomies, 
and the diminution of the watery elements of the blood following the inhala- 
tion of chloroform or ether; when one thinks of the loss of animal fluids 
which may take place, such as hemorrhage and persistent vomiting, neither 
of which can be foreseen ; when one recalls the irritating effects of ether on 



Cathartics — Hypnotics — Enemata 85 

the kidneys ; when one realizes the importance of gastro-intestinal rest after 
abdominal sections, which includes the withdrawing of all fluids for a 
greater or less time after the operation, I think you will agree that it is 
imperative to give the patient not only all the water desired, but encourage 
the drinking of a superabundance. It is common observation, however, in 
hospitals where the most elaborate preparations are made, to witness this 
common-sense necessity neglected. With those surgeons who do not use 
proctoclysis after celiotomies, but who permit water to be administered by 
the mouth immediately after nausea and vomiting have ceased, the super*- 
abundance of this fluid the day previous is especially indicated. Not because 
the administration at that time can in any way take the place of water admin- 
istered by way of the rectum after operative measures, but from the fact 
that it is an endeavor in a meager way of flushing the circulatory and 
urinary systems. Proctoclysis in postoperative cases, especially in celioto- 
mies, will sooner or later become thoroughly appreciated by a larger class 
of surgeons than at present recognize its beneficent effects, both as a means 
of flushing the economy and' permitting gastro-intestinal rest. 

The patient should drink at least two quarts of water the day previous to 
operation and as much more as possible; while food should cease six hours 
before the appointed time for operating, water may be continued to within 
three or four hours. 

Cathartics. — Castor oil (oleum ricini) is the best pre-operative cathartic. 
A sufficiently large dose (2 5) which will produce one or two copious 
evacuations of the bowel, should be given in the interval between dinner and 
supper. If less is administered, the patient is irritated by numerous small 
evacuations, and if taken before retiring the night's rest is disturbed. The 
unpleasant taste may be concealed by the use of some sour wine or lemon 
juice. Some operators use one of the different salines, others calomel, or a 
laxative pill of some kind. 

Hypnotics. — I am very much in favor of administering one of the newer 
hypnotics, such as veronal 10 grs. or trional 15 grs. to nervous patients the 
night previous to the operation. Eight or ten hours sleep affords rest, and 
obliterates the psychic effects the anticipated ordeal produces. 

Enemata. — At least four hours before being taken to the operating-room 
the patient should receive rectal enemata of soapsuds or normal salt solution 
to cleanse the lower bowel. If given later than this some portion of the 
enema may be ejected on the operating-table. 

Patient's Attire for the Operating-room. — A short time before the hour 
set for operation, prepare patient in following manner : A clean short mus- 
lin nightgown of the usual hospital pattern is placed on the patient, together 
w T ith a pair of long canton-flannel stockings reaching to the hips, and a 
turban made of two-ply 20 by 24-mesh gauze is adjusted to the head. 




Illustration XVI 

A Common but Improper Method of Hypodermatic Medication. Ob- 
jections to this method are that it produces more pain than is 
necessary, and increases the liability to infection because of the 
numerous glands which are penetrated by the needle. 




Illustration XVIa 



The Proper Method of Hypodermatic Medication. By this method 
fewer nerve endings are injured, and less pain is therefore pro- 
duced; infection from the superficial glands is reduced to a mini- 
mum. A short fine needle should be employed. The outer sur- 
face of one of the upper extremities is usually chosen as the site 
for injection. The needle must be sterilized by boiling, and the 
location for injection cleansed with alcohol before the drug is 
administered. 



(86) 



Alkaloidal-narcotic Medication 87 

Alkaloidal-narcotic Medication. — From half an hour to two hours before 
the anesthetic is to be administered it is the custom among a majority of sur- 
geons to order a hypodermatic injection of morhpin and atropin, or morphin 
and hyoscin (scopolamin). The reasons for the use of these drugs are: 

(1) It acts as a sedative to the nervous system and produces a quiescent 
state of the brain — very important points. 

(2) It prevents the accumulation of mucus in the throat and bronchi. 

(3) It "cuts out" the vagus nerve and thus prevents sudden collapse in 
the early part of the anesthetic (ether or chloroform), or in operations 
on the neck occurring in close proximity to this nerve the mechanical irrita- 
tion caused by the operative procedure may also develop similar results. 

(4) Less anesthetic is required (see lecture on "Anesthesia — Anesthetics," 
section "Mixed Anesthesia"). 

Catheterization. — This is the last step in the preparation of the patient. It 
is surprising how quickly urine collects in the bladders of nervous women, 
and frequently if allowed to urinate they will not entirely empty the viscus ; 
hence, the patient should be catheterized immediately before being sent to 
the anesthetizing-room; following out the same precautions of sterilization 
as have been given you. 

The transfer of the patient to the anesthetizing-room is accomplished on a 
wheel stretcher, equipped with a blanket folded to fit and a small pillow, the 
patient being covered with a blanket and clean sheet. 

BIBLIOGRAPHY. 
Operative Gynecology — Howard A. Kelly, A. B., M. D., LL. D. 



LECTURE IX 

POSITIONS OR POSTURES OF THE PATIENT UTILIZED 

IN SURGERY 

It frequently becomes necessary when making examinations of the patient, 
or when performing operations, to place the subject in certain postures 




Illustration XVII 
Sims's Posture (side view) 



which will facilitate the accomplishment of our purpose. The following 
are the most commonly used : 

(88) 



Sims's Posture 



89 



Sims's posture, also called the semiprone, was first brought to the atten- 
tion of the profession by Dr. Marion Sims. It is thus obtained — 

(1) All clothing such as waistbands are loosened. 

(2) Place the patient on her left side with legs and thighs partially flexed. 

(3) Left arm laying along the back or over the edge of the table. 

(4) Right thigh and leg over the left. 

(5) The right anterior spine tilted toward the top of the table. 



- 




Sims's Posture (end view).- 



Illustration XVIII 

-Note the incline of the right hip toward the surface 
of the table. 



If a Sims speculum or other vaginal retractor is now introduced in the 
vagina and the perineum retracted, the canal is at once ballooned with air, 
and the cervix comes into view. The position is used for examinations, 
topical applications to the uterus (cervix), and occasionally it is employed 
for operations on these parts. (See illustrations XVII and XVIII.) 



90 



Dorsal Recumbent 



Dorsal Recumbent.- — This is the usual position employed for examining 
patients with abdominal or pelvic diseases. It is obtained thus — 

(1) All tight clothing is loosened. 

(2) The patient is supine (lying on the back) on the table. 

(3) Elevate head and shoulders. 

(4) Flex limbs, by placing the patient's feet on the table or in stirrups. 

Thus the anterior abdominal muscles are relaxed, which allows a greater 
depth of palpation, — a closer contact, so to speak, with the abdominal organs. 
This is the position employed for bimanual examinations, — that is to say, 




Illustration XIX 

Dorsal Recumbent Position (side view)- — Note the shoulders elevated on a pillow 
and the thighs slightly flexed to facilitate the relaxation of the abdominal 
muscles. 



one hand of the examiner is placed above the symphysis pubis, crowding 
the pelvic viscera downward, while the other is in the vagina mapping out 
any abnormalities that are present. This position is also used in connection 
with the ordinary bivalve vaginal speculum to administer topical applications 
to the cervix uteri. (See illustrations XIX and XX.) 

Knee-chest Position is obtained by having the patient kneel on the exam- 
ining-table with the thighs perpendicular to its surface while the chest is 



Knee-chest Position 



91 



brought as close as possible to the plane of the same, — the face being turned 
to either side to permit this. The philosophy of the position is based on the 
fact that the intestines gravitate toward the diaphragm, thus relieving the 
vagina, bladder, and rectum of any superincumbent weight. By the intro- 




Illustratiox XX 

Dorsal Recumbent Position (end view). — This position is 
utilized for vaginal examinations. 



duction of a suitable speculum, either of these organs are dilated by the in- 
rush of air, and a thorough inspection can be obtained. The position is fre- 
quently utilized in adjusting retrodisplacements of the uterus. If extensive 
pelvic adhesions are present the ballooning of the hollow viscera will be im- 
perfect. (See illustrations XXI and XXII.) 



92 



DORSO-SACRAL POSTURE 



Dorsosacral, or Lithotomy Posture, is obtained thus — 

(1) Place the patient supine on the table. 

(2) Locate the buttocks to the edge of the same. 

(3) Flex the legs on the thighs and these on the abdomen. 

(4) Maintain the position by the usual leg-holders attached to the oper- 
ating-table or substitute the Clover crutch for these in private practice. 




Illustration XXI 

Knee-chest Position. — Patient on author's table, 
top flat. 



The position is used in operations on the cervix uteri, vagina, perineum, 
rectum, and in perineal prostatectomies. (See illustrations XXIII and 
XXIV.) 

The Trendelenberg Position. — This posture was introduced to the profes- 
sion by the surgeon whose name it bears. It consists in the elevation of the 



Trendelenberg Position 



93 



pelvis to an extent that will cause the intestines to gravitate toward the 
diaphragm ; they are maintained in that position by abdominal sponges, 
thus leaving this basin clear for operative interference. The amount of 
elevation necessary will vary from 20 to 45 degrees. There are various 




Illustration XXII 

Knee-chest Position. — Patient on author's table, 
shelf attachment utilized. Head of the table 
lowered so as to obtain a better distention of 
the pelvic organs which are to be examined. 



modifications of this position to which it will not be necessary for me to 
call your attention. The most satisfactory result is obtained in the fol- 
lowing manner — 

(1) Patient supine on the table. 

(2) The flexure of the knees so adjusted as to bring the same to the hinge 
portion of the "foot-drop leaf" to which the feet are attached, either by a 
leather strap provided for this purpose or a wide bandage. 

(3) The foot leaf is then dropped. 



94 



Trendelenberg Position 



(4) The head of the table is depressed, elevating the pelvis. Thus the 
patient is retained in position by the flexion of the limbs over the drop leaf 
to which they have been secured. This is preferable to having shoulder 
crutches. By referring to illustration XXV you will note that the thorax 
is not bent forward on the abdomen, which should be considered dangerous, 




Illustration XXIII 

Dorsosacral or Lithotomy Posture. — Note the leg- 
holders. This is the usual manner of obtaining- 
this position in hospital practice. 



but is on the same incline plane as the trunk, allowing free respiration — a 
point of great importance. 

The usefulness of this position cannot be overestimated in operations in 
the pelvis, but with the advantages this posture affords it carries with it cer- 
tain disadvantages, among which may be mentioned — 

(1) The pressure of the intestines and omentum against the diaphragm 
interfering with respiration, especially in obese patients. 



Hartley Position 



95 



(2) The gravitation of infectious material from the pelvis to the higher 
zones in the abdomen, in other words the spreading of infection. 

(3) The danger of secondary hemorrhage. I have on several occasions 
noted a field free from blood while the patient was in this position, but, 




Illustration XXIV 

Dorso-sacral or Lithotomy Posture. — Xote the 
Clover crutch retaining- the limbs in position. 
This retaining- apparatus is frequently used in 
private practice. 



when returned to normal position, hemorrhagic areas at once appeared. 
(See illustration XXV.) 

The Hartley Position. — This posture is named for its originator, Doctor 
Frank Hartley of Xew York; it is really a reverse Trendelenberg, and is 
accomplished in the following manner — 

(1) Place the patient recumbent on the table. 



96 



Fowler Position 



(2) Adjust the "foot-rest plate" so that its position corresponds to the 
soles of the feet, and prevents the subject from slipping when the head is 
elevated. 

(3) Strap the knees to the top of the table to prevent flexion when the 
patient's muscles relax from the effect of the anesthetic. 

(4) Elevate the trunk to an angle of about 30 degrees. 

This position is used chiefly in head and neck operations. (See illustra- 
tions XXVI and XXVII.) 




Illustration XXV 
Trendelenberg - Position 



The Fowler Position. — This was first suggested by Doctor Fowler of 
Brooklyn, and if the Trendelenberg position is a necessity during an opera- 
tion, the Fowler posture is equally efficacious before, during, and after 
operative interference. It is obtained by elevating the trunk 35 degrees to 
38 degrees. 

Mechanical Ways of Obtaining the Fowler Position. — Method One. — By 
placing an ordinary back-rest in the bed the necessary elevation can be 



Fowler Position 



97 



obtained, but the tendency of the patient to slide off the "rest" makes this a 
poor means of obtaining this position ; nevertheless it is mentioned inasmuch 
as circumstances frequently compel its employment. 

Method Tivo. — A device similar to the one shown in illustration XXX is 
placed under the head of the bed so as to produce the necessary degree of 
elevation. This method carries the same disadvantage as the former — the 
difficulty in preventing the patient from sliding toward the foot of the bed. 

Method Three. — I hope I may be permitted the latitude of preferring the 
double-inclined bed-frame which I originated, to any other method that has 




Illustration XXVI 

Table in the Hartley Position showing the foot-leaf employed to prevent the patient 
slipping- and. the head-rest used in operations on the neck to produce a convexity 
of that part. 



been brought to my notice. A glance at illustration XXVIII will explain its 
mechanical details. 

Advantages of this Bed-frame. — 

(1) Being made of steel it can be cleansed. 

(2) It is comparatively light, so that it may be easily transferred from 
place to place by one nurse. 

(3) It retains the patient in position. 

(4) It relaxes the traumatized abdominal wall and thus affords relief. 

(5) It assists rapid venous return from the lower extremities, possibly 
preventing thrombophlebitis. (See illustrations XXVIII and XXIX. Illus- 
tration XXX gives another means of obtaining the same position.) 



98 



Fowler Position 



The Fowler Position is based on anatomic and physiologic principles, 
among which may be formulated the following — 

(1) There is a peritoneal current tending from the pelvis to the dia- 
phragm at all times and under all circumstances irrespective of the position 
of the subject, whether erect, lying flat, or with pelvis elevated and head 
down on an incline plane. 

(2) This current can be retarded "by a position opposed to gravity" 
(John L. Yates, M. D.) that is to say, the nearer the erect posture of the 
trunk, the slower will be this current. 




Illustration XXVII 
Hartley Position. — Note the convexity of the neck of the patient 



(3) The pelvis is supplied with few lymphatics, comparatively speaking, 
and is therefore a harbor of safety when infection is present. 

(4) The region around the diaphragm is richly supplied with these 
absorbents, — hence a zone for rapid absorption in the presence of infection. 

(5) This peritoneal current is promoted by respiration, peristalsis, etc. 

The object of the Fowler position therefore is to retard the peritoneal cur- 
rent to the extent that absorption at the diaphragm will be proportionately 
minimized; thus if there is an infection or infectious material in the pelvis, 



Fowler Position 



99 



the current will carry such infection to the dangerous zone of the diaphragm 
so slowly that when absorption takes place the body-resistance will be more 
capable of taking care of it than if the current was given full sway and 
allowed to overwhelm the body forces. 

When the subject is supine there will be seen a concavity on either side of 
the vertebral column below the diaphragm, the so-called flanks; these are 
separated from the pelvis by a prominence known as the promontory of the 
sacrum, aided by the psoas muscles. The question necessary to be settled 
is, what degree will the trunk have to be elevated to drain the flanks into 
the pelvis? During operations in the Trendelenberg posture, infectious 




Illustration XXVIII 
Showing- the author's bed-frame to obtain the Fowler Position 



material will gravitate into the flanks, a zone where absorption is rapid, or 
in operations in the upper abdomen this same accident may occur. I at- 
tempted to solve this problem with the assistance of a mechanical engineer. 
The abdomens of eight cadavers were eviscerated ; beginning immediately 
under the diaphragm, levels were made of the cavity every one-half inch 
until the lowest portion of the pelvis was reached ; the results demonstrated 
that it required from 35 degrees to 38 degrees of elevation to accomplish this 
postural drainage. There was little or no difference between male and 
female subjects. In utilizing the Fowler position these deductions should be 



100 



Fowler Position 



borne in mind as it is common observation to witness some patients nearly 
erect, and others practically not taken off the plane of the bed; moreover 
clinical experience has confirmed the fact that the angles I have suggested 
retard the peritoneal current sufficiently. But it is not in postoperative 
cases alone that the Fowler position should be utilized. If this posture were 
more frequently employed in acute intraperitoneal infections, together with 
g astro -intestinal rest and proctoclysis many cases which are placed on the 
operating-table at the height of infection could be postponed until such 




Illustration XXIX 
Patient in Fowler Position. Author's frame being- utilized for the purpose 



infection was under control or circumscribed. (See lecture on "Principles 
and Practice of Postoperative Nursing," sections "Water and Nourish- 
ment.") Thus cases of fulminating appendicitis should be placed in the 
Fowler position before operative interference, maintained in this posture 
during the operation, and retained in the same after leaving the operating- 
room. 

I hardly need state, that in all of these positions, especially those for pur- 
poses of examination, the patient should never be unnecessarily exposed. 



Fowler Position 



101 



One of the most distasteful sights is to see a careless nure in this respect, 
the esthetic should be practiced and vulgar exposure carefully avoided. 





Illustration XXX 

Patient in the Fowler Position. The mechanical means here illustrated can be 
utilized in private practice. 



BIBLIOGRAPHY. 

Operative Gynecology — Howard A. Kelly, M. D. 

An Experimental Study of Intraperitoneal Diffusion — John L. Yates, 
Ph. B., M. D., Wilwaukee, Wis. 



LECTURE X 

THE BLOOD-VESSELS 

It is not the province of these lectures to deal with the subject of anatomy, 
but that the discussion of the next few subjects may be more clearly under- 
stood, I desire to call your attention to some of the anatomical rudiments of 
the blood-vessels. 

The vascular system may be divided into three divisions, viz., (1) the 
arteries which carry the oxygenated blood from the heart with nutritive 
material for the tissues, (2) the veins which return the deoxygenated blood 
to the heart after the tissues have received their nutrition from the arterial 
blood, and (3) the capillaries, — the connecting links between the arteries 
and veins. Where the small arteries end the capillaries begin, and where the 
small veins begin the capillaries end. The arteries are branches of one large 
vessel, the aorta, which originates at the upper part of the left ventricle of 
the heart. This vessel divides and subdivides throughout the economy until 
it terminates in small twigs. The veins begin at the termination of the capil- 
laries in minute vessels. These increase in size on their way back to the 
heart by constantly joining with each other until two trunks are formed, the 
superior and inferior vena cava which empty into the right auricle. The 
superior vena cava returns the blood from the upper portion of the body, the 
inferior from all parts of the economy below the diaphragm. The return 
flow of blood through the veins is therefore laboring under a mechanical dis- 
advantage. The veins are supplied with valves, especially in those regions 
of the body where large columns of blood are present, as in the veins of the 
extremities. Their function is to prevent any backward movement of the 
circulation. 

The arteries in their course communicate freely with each other, the same 
is true of the veins ; not only is this seen in the larger vessels, but in the 
small ones as well. The communication is known as an anastomosis, or 
inosculation. Thus the branches of an artery or vein above a joint will com- 
municate or anastomose with branches of some other artery or vein below 
the articulation. Moreover after the circulation has been checked in its 
usual course by the use of a ligature, as in surgical operations, and the 
blood-current directed into new paths the increased volume of the blood 

(102) 



Histology of Blood-vessels 103 

causes an enlargement of the vessels through which it passes. When the 
vessels have sufficiently enlarged to take care of the extra amount of blood 
which has been forced through them, a collateral circulation is said to have 
been established. You can easily understand how important this is to a sur- 
geon. Occasionally, however, a collateral circulation is not established after 
the ligation of a vessel, or only partially so; the consequence is (1) the part 
dies from lack of nutrition, or (2) the part suffers from malnutrition. 
There are certain arteries that do not anastomose, in which therefore a col- 
lateral circulation could not be established should these vessels become 
occluded ; these are termed terminal arteries. 

Histology (Minute Anatomy). — The walls of the arteries possess three 
coats, — the internal, middle, and external. These are composed of muscu- 
lar and elastic tissues bound together by connective tissue. The larger the 
artery, the greater is the development of muscular and elastic fibers. On 
the free surface of the inner coat, that is over which the blood-current flows, 
is a delicate, smooth, and polished membrane composed of endothelial cells, 
the functions of which are (1) to prevent the coagulation of the blood, 
(2) to reduce to a minimum the amount of resistance to the current, — in 
other words it is the antifriction surface, (3) to aid in the repair of injured 
vessels. 

The capillaries are composed of a single layer of endothelial cells ; the 
muscular and elastic fibers which were found in the veins and arteries are 
not present in these tubules. 

The coats of the arteries and veins receive their nutrition from minute 
vessels originating from themselves, known as the vasa vasorum. 

All blood-vessels are supplied by minute nerve filaments known as the 
vasomotor nerves. These acting on the elastic and muscular fibers of the 
wall, contract and dilate the caliber of the vessel according to the needs of 
the economy, — more of which will be spoken of in the lectures on "Surgical 
Shock" and "Hemorrhage." 

Lymphatics are also found in the external coat of blood-vessels. 

Process of Repair of Blood-vessels. — The inner coat of the blood-vessels 
plays a very important part in the process of their repair. When injured 
this tunic has a tendency to "curl up" within the caliber of the vessel, thus 
causing some obstruction to the blood-current; possibly this hindrance is 
very slight, yet nevertheless this together with the elimination of fibrin (a 
product of the blood) causes a clot or thrombus to form which is the first 
step in the process of vessel-wound repair. The endothelium which lines 
the inner coat now proliferates and covers this clot; soon elastic and fibrous 
cells from the other coats of the vessel multiply and penetrate the thickness 
of the thrombus. Leukocytes, which are ever present in increased numbers 



104 Repair of Blood-vessels 

where an injury occurs or an infection is imminent, begin their work of 
removing the clot which was primarily formed. In this way as fast as the 
clot is being removed, fibrous and elastic cells from the middle and outer 
coats are taking its place, until the injury is repaired by these new cells. If 
the area involved is large, minute vessels from the vasa vasorum penetrate 
this new tissue to supply it with nutrition. A process of contraction begins in 
these newly formed cells, and a cicatrix or scar tissue develops which is the 
final result of all wounds. (See lecture on "Wounds," section "Repair.") 

A process similar to what has been described occurs when a vessel is 
ligated, that is — 

(1) The inner and middle coats are ruptured by the ligature. 

(2) The inner coat curls within the caliber of the vessel. 

(3) Elimination of fibrin, the result of injury to the inner coat and blood- 
cells. 

(4) Formation of clot at site of injury, due to the second and third steps. 

(5) The thrombus or clot is covered with endothelial cells from the 
inner coat. 

(6) Proliferation of fibrous and elastic cells from the middle and outer 
coats of the vessel. 

(7) Penetration of these cells through the clot to form new tissue. 

(8) Absorption of clot by leukocytes as rapidly as new elastic and fibrous 
cells are formed. 

(9) Development of minute blood-vessels from the vasa vasorum to sup- 
ply this newly formed "plug" with nutrition. 

(10) Contraction of this new tissue, formation of a scar. 



LECTURE XI 

TRANSFUSION— INFUSION 

The term transfusion is limited at the present time to that process by 
which the arterial blood of one individual is caused to flow into the veins of 
another. The idea itself is old, but fell into disuse on account of what was 
formerly considered insurmountable difficulties. Through the ingenuity of 
Dr. Geo. W. Crile of Cleveland, Ohio, it was revived and placed on a 
practical basis. 

You can easily understand that in cases of severe shock, where the blood- 
vessels are greatly relaxed (see lecture on "Surgical Shock"), or in cases of 
exsanguination (depletion of blood), no artificial fluid could be injected into 
the vessels that would compare with normal blood. All the elements of 
nutrition are found in it. It is the physiologic and natural fluid, therefore 
it meets all the requirements instantly ; furthermore, regardless of the amount, 
the transfused blood is retained, and does not exude through the coats of the 
vessels as when saline solutions are administered in large amounts. 

Moreover, transfusion affords the only means at our command of permit- 
ting immediate operations on those patients who are either reduced to such 
a low ebb by protracted disease or by emergencies where further procras* 
tination means a fatality. 

The one giving the blood is known as the donor, while the recipient is 
called the donee. Like every other innovation it is not thoroughly under- 
stood, consequently the results have been disastrous in many cases. It must 
be borne in mind that the blood of one individual may not be compatible (if 
I may be allowed that expression) with that of another, that is to say the 
blood-corpuscles of the donor may be disintegrated by the blood-serum of 
the donee and the hemoglobin set free ; a condition known as hemolysis. You 
can easily appreciate therefore the amount of toxemia which is capable of 
being produced in a transfusion of 500 c.c. of blood if a hemolytic action 
occurs. In operations where hemorrhage and shock are expected, a test is 
made of the two bloods to ascertain if hemolysis is present the day previous 
to operation ; but in emergency cases, where the patient is "in extremis'' 
there is no time for such a test, and the transfusion is made from any 
healthy individual who will give the blood. 

There is no way of estimating the amount of blood transfused; in fact, 
for practical purposes it is not necessary. The object of transfusion is 

(105) " 



106 Infusion 

primarily to raise the blood-pressure. (See lecture on "Surgical Shock.") 
This being brought approximately to the normal point dissolution cannot 
take place from shock, hemorrhage, or other surgical emergencies. Blood- 
pressure is estimated by an instrument known as a sphygmomanometer. 
(See lecture on "Surgical Shock," section "Blood-pressure.") If one of 
these is applied to the arm of the donor and another to the donee, the read- 
ings will indicate the ascension of blood-pressure in the latter and the 
descension of the same in the former. When the donee has received a suffi- 
cient amount of this fluid to raise the blood-pressure near the normal point, 
or preferably above it, the transfusion should cease. There is no risk to the 
donor if the sphygmomanometer is used. 

Accessories Necessary for Transfusion. — 

(1) 1 sharp scalpel. 

(2) 1 pair of dissecting forceps. 

(3) 1 blunt dissector. 

(4) 6 small hemostats, commonly known as "mosquito" forceps. 

(5) 4 Crile carotid clamps. 

(6) Assorted sizes of Crile's anastomosis cannulae. 

(7) Cocain solution (2 per cent.) and hypodermic syringe. 

(8) Needle holder, needles, No. 1 catgut, and No. 000 pagenstecher. 

(9) 1 or 2 sphygmomanometers. 

Infusion. — By the term infusion as applied to surgery is understood the 
introduction into the circulation of normal saline solution. This may be 
accomplished in either of the following ways : 

(1) Directly into the vein, intravenous infusion. 

(2) By way of the rectum, proctoclysis, cnteroclysis, or rectal infusion. 

(3) Into the cellular tissue, hypodermoclysis. 

(4) The solution may be introduced into the peritoneal cavity, a locality 
where absorption is rapid, to which the term intra-abdominal infusion is 
applied. 

General Effects of an Infusion. — 

(1) It stimulates the circulation by assisting to fill the relaxed vessels in 
cases of shock, and forms a temporary substitute fluid in cases of hemor- 
rhage, — therefore increases blood-pressure. 

(2) It affords a means of giving fluids to the patient when unable to take 
water by the mouth from physical inability, or when gastro-intestinal rest 
is required. 

(3) It dilutes infectious material when present in the blood-current. 



Intravenous Infusion 



107 



(4) It increases the fluidity and volume of the blood, which together with 
the rise in blood-pressure stimulates the function of the kidneys ; moreover, 
in infectious diseases, the integrity of these organs is preserved as the result 
of the dilution of the toxins. 

(5) Its presence in the circulation produces a leukocytosis. 

An analysis therefore of its various effects demonstrates that it is a great 
factor in conserving natural resistance. 

Intravenous Infusion. — Of the four different ways I have mentioned of 
•getting a saline solution into the circulation, the intravenous is preferable 
when a quick and rapid stimulation is the desired end, and time means every- 




Illustration XXXI 

Infusion Bottle with saline solution under air 
pressure. 



thing to the patient, as in cases of shock and hemorrhage; because in this 
way the infusion is delivered directly into the relaxed vessels and fills their 
lumen immediately instead of having to be absorbed before reaching the 
circulation. 

No elaborate apparatus is necessary to carry out this technic; the outfit 
mentioned in the lecture on "Ward Service," which is always sterilized 
ready for use, is employed. 

Infusion Reservoir. — The numerous complex reservoirs on the market for 
the administration of the saline solution, to which are attached bulbs or 



108 



Infusion Reservoir 



pumps to produce air pressure, are absolutely unnecessary and occasionally 
harmful. There is no way of estimating the amount of air pressure, which 
varies constantly, and consequently the force of the stream into the circula- 
tion changes proportionately. (See illustration XXXI.) 



Sfe 




Illustration XXXII 



Author's Infusion Reservoir. — Note the 
double jacket which is filled with hot 
water to maintain the temperature of 
the saline solution in the glass reser- 
voir; also observe the by-pass' stop- 
cock in the tubing- leading to the in- 
fusion needle. The reservoir is raised 
or lowered by a telescopic tube which 
fits in the standard. 



The reservoir I prefer is simply a graduated glass percolator, suspended 
at a variable height, equipped with rubber tubing, the necessary needle, and 
a by-pass stopcock. The by-pass indicates at any time during the operation 
the rapidity of the flow. The reservoir can be raised or lowered to increase 
or diminish the current. Frequently when administering an infusion for 
shock or hemorrhage, it is necessary to allow the current to flow rapidly at 



Nurse's Duties 109 

first for its stimulating effect, and gradually modify the outflow through 
fear of blocking the heart's action. This cannot be accomplished with the 
same precision when using air-pressure bottles. (See illustration XXXII.) 

Infusion Needles. — There are two varieties, sharp and dull pointed; the 
latter occasionally have an olive-shaped tip. The sharp-pointed needles 
should not be used. The ease with which the coat of the vessel can be punc- 
tured by any sudden move of the patient is sufficient reason for rejecting 
them. 

Choice of Location for Intravenous Infusion. — Any superficial vein can 
be used for infusion. Usually one on the anterior surface of the elbow 
(median bacilic or median cephalic) is chosen. 

Inasmuch as the surgeon performs the operation of infusion I will pass to 
the duties of the nurse. 

Nurse's Duties. — 

(1) Obtain a complete infusion outfit as described in "Ward Service." 

(2) Heat one of the flasks containing the normal saline solution. 

(3) Carefully remove the outer wrapper of the package containing the 
accessories. Avoid soiling the inner wrapper. 

(4) Cleanse hands, adjust gown and gloves. 

(5) Prepare the field for infusion according to one of the methods de- 
scribed, protecting the arm and forearm above and below the field with 
sterile towels moistened in mercuric solution 1 :2000. 

(6) Arrange sterile towels in such a manner that the field is not contami- 
nated by contact with bedding, etc. 

(7) Encircle the arm above the field with a bandage snugly applied. This 
brings the veins prominently into view. 

(8) Prepare cocain solution according to surgeon's directions (generally 
2-per cent, solution). If the patient is unconscious this step is omitted. 

(9) Partially fill the reservoir with the hot saline solution; modify the 
temperature with the cold solution until the thermometer (which is placed in 
the reservoir) indicates 120° F. 

(10) Add 30 minims of solution adrenalin chlorid to every pint of infu- 
sion fluid. 

(11) Care should be exercised by the nurse to ascertain if all air is ex- 
pelled from the tube and needle before giving it to the surgeon to introduce 
into the vein. 

(12) Release the bandage with which the arm is encircled after the sur- 
geon has secured the needle in the vein. 



1 10 Proctoclysis — Enteroclysis 

(13) Keep the field moistened with warm saline solution to prevent clot- 
ting of the blood. 

(14) Pay strict attention to the pulse. If improvement is noted, it 
indicates the heart is capable of handling the extra fluid that is being thrown 
into the circulation, but if on the contrary the pulse becomes weaker, it is an 
indication that the heart is being "overcrowded." The nurse should then 
cease administering the infusion by shutting off the stopcock and notify the 
surgical attendant if this latter is not present. 

(15) As soon as the desired amount (about two pints) is administered 
the surgeon ligates the vein and closes the wound; the nurse cleanses the 
arm and applies a sterile dressing. 

Frequent Modification. — When during the administration of an intra- 
venous infusion, an immediate and pronounced effect of adrenalin chlorid 
is needed (as in severe cases of shock and hemorrhage), the surgeon will 
inject by means of a hypodermic syringe a few drops (5 to 10) of the 
drug into the main tube of the irrigator about an inch above the intravenous 
needle. This is in addition to the adrenalin chlorid contained in the saline 
infusion. 

Proctoclysis — Enteroclysis or Rectal Infusion. — Some one has said, "we eat 
by means of the small intestines, and drink through the medium of the large 
bowel." That is to say, the material contained within the duodenum, 
jejunum, and the ileum is of a semifluid consistency, but during its passage 
through the colon, sigmoid, and rectum absorption of the fluid portion 
occurs. This primitive knowledge was the basis on which our present prin- 
ciples of proctoclysis were developed. 

To Dr. John B. Murphy the profession is indebted for the proper technic 
of rectal infusion, and the demonstration of its vast field of usefulness. The 
method which he advocates is based on physiologic principles and supple- 
mented by the laws of physics. The following essentials as set forth by Dr. 
Murphy must be thoroughly understood to successfully administer a 
proctoclysis : 

(1) The fecal material enters the large intestine in a semifluid state. In 
its passage through this portion of the gut the fluid is extracted by absorp- 
tion. The large bowel therefore is a "dryer" of the alimentary canal. 

(2) The natural condition of the large intestine is one of distention. 

(3) The material in the large bowel is held under low tension, — about a 
four-inch hydraulic pressure ; this is increased possibly to a six-inch pressure 
in the presence of an inflammatory condition within the abdomen. 

(4) If this tension or pressure is increased it causes a spasm of the boivel 
and discomfort, which is relieved only by expulsion of the material which 
developed the abnormal tension. 



Principles of Proctoclysis 



111 



The deductions drawn from these physiologic principles, and which have 
been corroborated by clinical experience, are — 

(1) That the large intestine is capable of rapidly absorbing large volumes 
of bland, isotonic fluids — sixteen to thirty pints per day. 

(2) That expulsion of the fluid (no matter how rapidly it is given) will 
not occur if the increased pressure caused by its presence within the gut does 
not exceed a four-inch hydraulic pressure; or possibly a six-inch pressure 




Illustration XXXIII 

Author's Proctoclysis Outfit 



when a general inflammatory condition is present within the abdomen (a 
peritonitis). Furthermore, the fluid will not How in rapidly with that 
pressure because it meets with an equal tension or pressure within the bowel, 
therefore the outlet of the reservoir containing the fluid should never be 
more than six inches above the level of the rectum. 

(3) That a fluid admitted in the bowel by the drop or any other method, 
when it accumulates there, attains a pressure equal to the hydraulic pressure 



112 Proctoclysis Outfit 

produced by the height of the reservoir; and if the outlet of the reservoir is 
elevated more than four to six inches the pressure in the intestine will be 
increased to such an excess as to cause an expulsion of the fluid. 

(4) That if the pressure within the large intestine is increased above 
normal by the formation of gas within the intestine when the fluid is being 
admitted the bowel will endeavor to expel it. 

(5) That the fluid of choice for proctoclysis is the physiologic saline or 
normal salt solution, because 

(a) It is bland and isotonic. 

(b) Its presence in the bowel does not produce irritation nor cause the 

epithelium to become swollen as when plain water is used. 

(c) Large volumes are therefore capable of being absorbed. (See 

lecture on "Preparation and Sterilization of Gowns/' etc., section 
"Normal Salt Solution.") 

Types of Apparatus for Proctoclysis. — There are numerous varieties of 
apparatus for the administration of saline infusion into the rectum, — the 
complicated types are unnecessary. A simple and convenient apparatus is 
seen in illustration, the design of which is based entirely on Dr. Murphy's 
ideas. No originality whatever is claimed excepting possibly the method 
of keeping the saline infusion warm, and the graduated standard which 
regulates exactly the height of the reservoir — a point of great practical- 
importance. 

Requirements for a Proctoclysis Outfit. — This may be termed a double- 
tube apparatus inasmuch as a safety return tube is used. (See illustration 
XXXIII.) 

(a) A standard made from steel tubing. 

(b) A check-nut. 

(c) An extension-rod which telescopes in the tube (a) and is main- 

tained at any desired height by the check-nut (b). This exten- 
sion is graduated in inches, and indicates the exact height of the 
reservoir. 

(d) A double copper jacket filled with hot water to maintain the tem- 

perature of the saline solution in the glass reservoir. 

(e) The inlet for hot water in the double copper jacket. 

(f) Glass percolator (surrounded by the double copper jacket) as a 

reservoir for the normal saline solution. 

(g) Main outlet from the reservoir of rubber tubing one-half inch in 

diameter. 

(h) Stop-cock to regulate the flow. 



Proctoclysis Outfit 



113 



(i) Glass Y, one-half inch in diameter. 

(k) Rubber tubing, one-half inch in diameter, connecting glass Y (i) 
with rectal nozzle (1). 

(1) Rectal nozzle of glass or hard or soft rubber. The material is of 
little consequence providing it is so constructed that it contains 
at least five holes, each of which is one-eighth of an inch in diam- 
eter. These several openings are made large, not to facilitate 
the solution entering the rectum, but to afford a free exit from 




Illustration XXXIV 

An Extemporized Proctoclysis Outfit for use 

in private practice. 



the bowel for any material which is ejected by an expulsive 
action of the intestine. The nozzle must be curved at such an 
angle as to easily lay within the rectum and not cause pressure 
on the walls of that organ. 

(m) Safety return tube (half-inch rubber hose). 

(n) Glass tube terminal (one-half inch in diameter) of safety return 
tube, hooked over the upper end of the glass reservoir. When 



114 Proctoclysis Outfit 

because of increased pressure within the intestine an expulsive action takes 
place, the -fluid passes through the large openings in the rectal nozzle (1), 
through the left arm of the glass Y, through the safety tube (m), and finally 
empties back into the reservoir — the path of least resistance. 

Description of Illustration XXXIV. — This is simply an extemporized 
apparatus suggested by Dr. Murphy for use in private practice, the only 
difference from the preceding outfit being the following: 

(1) An ordinary porcelain douchecan is used as a reservoir. 

(2) The saline solution is kept warm by Turkish towels wrapped around 
the can. 

(3) A hemostat is used in place of a stopcock. 

To the thoughtful student who has given this subject any consideration, 
two questions must necessarily arise. 

(1) What is the need of a stopcock if the reservoir is suspended at a cor- 
rect elevation (four to six inches), so that the pressure of water flowing 
into the bowel is practically equivalent to that within the intestine, the 
rapidity of the current from the nozzle being controlled by the pressure 
zuithin the gut? 

(2) What is the necessity of having a safety return tube if the main 
outlet tube is sufficient to care for the back-flow if any occurs? 

The answer is, to equip the apparatus in such a manner as to make it 
"fool-proof," if I may be permitted to use the expression. 

The Murphy proctoclysis may be successfully administered with a single- 
tube apparatus if the following cardinal points are observed : 

(1) The suspension reservoir must never exceed six inches from the 
plane of the rectum, in many cases a less degree of elevation is advisable. 

(2) The tube which answers the double purpose as an inlet for the saline 
solution to the rectum and as a back-flow from that organ in case of bowel 
spasm, must have a caliber of at least one-half inch. 

(3) The rectal nozzle must be of ample bore and constructed with at 
least five holes, each of which is one-eighth inch in diameter, so as to permit 
free exit of any fluid when the tension within the bowel is increased. 

(4) No hemostat or stopcock is permissible to regulate the flow. These 
mechanical appliances so constrict the single tube as to obstruct the back- 
flow, should spasm of the bowel ensue. The contents of the intestine as 
usual would take the path of least resistance, which in this case would be at 
the rectal sphincter. The flozv in a single-tube infusion apparatus must be 



Administration of Proctoclysis 



115 



regulated solely and entirely by the height of the outlet of the reservoir 
(four to six inches) and pressure within the intestine. 

Administration of a Proctoclysis. — Nurses Duties. — 
(1) The position of the patient in bed does not interfere with the admin- 
istration of a rectal infusion; that is to say, the patient may be supine, on 




Illustration XXXV 

Proctoclysis Outfit in Position. — Note the height of the bottom of the reservoir as 
to the rectum — four to six inches — not suspended one to two feet above that 
organ as is commonly witnessed. 



the side, in the Fowler position, or in the "head-down" or ''foot-elevated" 
position. 

(2) Prepare suspension reservoir according to one of the methods sug- 
gested above. 

(3) Fill the reservoir with normal saline solution at a temperature of 
105 °F. This is regulated by a thermometer placed within the reservoir. 

(4) Suspend the reservoir so that the bottom is from four to six inches 
above the rectum. There should be no guess work regarding the height of 
suspension. If an inflammatory action is present, or much distention of the 
boivel, a six-inch elevation is permissible, otherwise any point between that 



116 Field of Usefulness 

and four inches. Permit the flow from the reservoir to expel all air from 
the tube. 

(5) Insert the nozzle in the rectum and do not remove it with each infu- 
sion, but allow it to remain in place. The constant inserting and removing 
produces an irritation of the organ and finally causes intolerance. 

(6) Make provision for keeping the saline solution in the reservoir at 
105°F. if the apparatus is not provided with such means. 

(7) Secure to thigh the tube leading to the rectum with straps of adhesive 
plaster about three inches above the rectal nozzle. (See illustration XXXV.) 

To the amateur and to those who do not understand the philosophy of the 
law of physics which I have endeavored to explain with regard to the 
pressure of the current being maintained at an equivalent pressure to that 
which exists within the bowel, viz., a four- to six-inch hydraulic pressure, 
the use of the stopcock becomes a necessity in connection with a safety-tube 
equipment. To this class my advice is to regulate the flow by the use of the 
stopcock to about three drops per second previous to its insertion into the 
bowel and suspend the reservoir four to six inches above the rectum. The 
average person does not appreciate the increased pressure produced in the 
bowel by elevating the reservoir an additional inch, otherwise more care 
would be exercised in its adjustment. 

I can think of no one adjuvant which has been given to the profession 
that has a wider range than proctoclysis. Its true value has not yet been 
appreciated. The lack of knowledge of the fundamental principles involved 
in its administration has prevented it assuming the important position which 
it is destined to occupy. In order to obtain the desired effects from a 
proctoclysis sufficiently large volumes of the infusion must be absorbed, 
because its action is more or less mechanical. The failure to obtain absorp- 
tion of the desired volume is due to an improper technic. Only those who 
have carefully studied the subject and have been successful in its adminis- 
tration, can appreciate its extensive field of application. I am fully aware 
that after a certain amount of infusion has been thrown into the circulation 
transudation occurs from the vessels and the deeper viscera, and conse- 
quently only a certain amount is primarily absorbed. That portion which 
has transuded is reabsorbed, again thrown into the circulation, and even- 
tually eliminated, carrying with it the toxins and other waste products with 
which the fluid has come in contact. Thus a continuous cycle of absorption, 
transudation, reabsorption, and finally elimination through the kidneys is 
occurring within the economy. The kidneys in this process are protected by 
the dilution of the toxic material, which otherwise would produce such 
pathologic changes in their structure as to compromise their function. It is 



Hypodermoclysis 117 

advisable therefore to cease the administration of a proctoclysis at definite 
intervals to permit the reabsorption of such portions as have transuded. 

In this connection Dr. Murphy says : "We give a pint and a half of 
normal salt solution every two hours, and so arrange the elevation of the 
can that it takes an hour or an hour and a quarter for that quantity to flow 
in. If the drop method is arranged that means about 45 drops in 15 seconds." 

Subcutaneous Infusion — Hypodermoclysis. — I consider it a difficult matter 
to find a suitable field for the use of a hypodermoclysis. If the patient is 
"in extremis'' from shock or hemorrhage, the intravenous infusion is cer- 
tainly the method of choice when blood for transfusion cannot be obtained; 
while if the condition of the patient demands a saline infusion, yet the case 
is not an emergency, when time is not an important element, then proc- 
toclysis as practiced after Dr. John B. Murphy's method is preferable. 

Disadvantages of Hypodermoclysis. — 

(1) Absorption is comparatively slow at all times, and in some cases a 
sufficient amount of the solution will not be absorbed. 

(2) The process is painful. 

(3) If great care is not exercised, the pressure of the fluid on the sur- 
rounding tissues may cause a devitalization and slough; this is especially true 
in obese subjects. 

Choice of Location for Hypodermoclysis. — The sites for the subcutaneous 
introduction of normal saline are under the mammary glands in the female, 
in the loose cellular tissue at the side of the scapula or in the subcutaneous 
tissues of the flanks in the male. 

Accessories Necessary for Hypodermoclysis. — 

(1) Infusion needle, sharp-pointed, medium size. 

(2) One flask of hot and one of cold normal saline solution. 

(3) Suspension reservoir as described in section on "Intravenous 
Infusion." 

(4) One bath thermometer. 

(5) Hypodermic syringe and solution cocain (2 per cent.) for local 
anesthesia. 

(6) Ethereal collodion. 

(7) Two packages of ward dressings. 

(8) Solutions and antiseptics for cleansing the field. 

In some hospitals, the head nurse of the floor is allowed to administer 
subcutaneous infusions. This is proper : she has had experience on account 
of her service; she appreciates the flow must be regulated in proportion to 



118 Intra-abdominal Infusion 

the absorption, and the temperature maintained in the reservoir. In private 
practice circumstances may arise which compel the nurse to resort to this 
method of stimulation in the absence of the surgeon. I will therefore 
describe the method of administration. 

Method of Administration. — Nurse's Duties. — 

(1) Cleanse hands, assume sterile gown and gloves. 

(2) Cleanse field for infusion according to one of the established rules. 

(3) Protect field by judicious use of towels placed about the patient. 

(4) Cocainize the area in which the infusion needle will enter. (Using 
2 per cent.) 

(5) Partially fill the reservoir with the hot saline solution; modify it with 
the cold until a temperature of about 115°F. is obtained, which must be 
kept at this point throughout the operation. Two pints are generally used. 
Note the absence of the solution of adrenalin chlorid in the composition of 
the above. The stimulating effects of this drug are only obtained when 
introduced directly into the vessel, otherwise its action is purely local. The 
temperature of the solution in the reservoir is higher than that used in 
proctoclysis, because the fluid must enter the tissues very slowly. 

(6) Introduce the needle into the cellular tissue of the part selected for 
the infusion, care being exercised to expel all air in the tube. 

(7) Regulate the flow in proportion to the absorption of the fluid. If the 
solution is deposited in the cellular tissue faster than it is absorbed, the 
pressure thus exercised may cause a slough. 

(8) During the administration of the solution, the field and surrounding 
tissues should be massaged to induce absorption. 

(9) When the desired amount has been given the needle is withdrawn, 
the hole or exit sealed with collodion, and a small dressing applied, held in 
place by adhesive plaster. 

Intra-abdominal Infusion. — Formerly after abdominal operations some 
surgeons infused from one pint to a quart of normal salt solution in the 
peritoneal cavity, with the following objects in view: 

(1) To dilute infection and cause rapid absorption, thus hoping to pre- 
vent peritonitis. 

(2) To produce a stimulating effect on the circulation and thus increase 
the urinary secretion. 

(3) To relieve thirst. 

(4) To prevent peritoneal adhesions. 

This method is seldom used at the present time; no advantages can be 
gained by its use. 



LECTURE XII 

SURGICAL SHOCK 

One of the most important subjects in surgical literature is Shock, and as 
nurses you should understand some of the underlying principles and 
phenomena connected with this complex condition. To Dr. G. W. Crile of 
Cleveland, Ohio, the profession owes a lasting debt of gratitude for his 
investigations and conclusions along these lines. Wherever surgery is 
taught, or medicine is practiced, the name of this incomparable investigator 
is linked with this symptom complex, and therefore whatever deductions, 
conclusions, and statements I may make are to be attributed entirely to what 
he has given us. 

Blood-pressure. — Shock may be defined as a partial or complete paralysis 
of the vasoconstrictor center in the medulla, causing such a dilatation of the 
blood-vessels as to produce an abnormal decrease in blood-pressure. Fall in 
blood-pressure is the keynote. It is therefore necessary for me to endeavor 
to explain to you what is meant by this term. Blood-pressure is the amount 
of pressure produced by the blood in the blood-vessels. This depends on 
several factors, chief among which may be mentioned (1) the condition 
of the vasomotor center which is situated in the medulla; (2) the amount 
of force exercised by the left ventricle of the heart in propelling the blood 
through the systemic circulation, and (3) the condition of the blood-vessels 
through which the blood circulates. 

Take the radial artery at the wrist of a subject as in the act of counting 
the pulse ; the amount of pressure exercised to obliterate the pulsation is 
really the blood-pressure, minus the pressure it requires to compress the wall 
of the vessel, but inasmuch as the tactile touch is not accurate enough to 
define the amount of pressure made to accomplish this object, some sensitive 
mechanism must be substituted. This apparatus is known as a sphygmo- 
manometer. 

The pressure of blood in an average normal adult should be capable of 
raising a given column of mercury to a height varying from 110 to 130 m.m. 

(119) 



120 Causes of Shock 

Hence, in stating blood-pressure it is expressed in mercurial millimeters 
thus, m.m.Hg. 

Vasomotor Nerves. — Surrounding the blood-vessels of the body are 
minute nerve filaments distributed to the muscular tunic or coat, known as 
the vasomotor; some of these filaments dilate the caliber and are known as 
the vasodilators, while others contract the bore of the vessels and are known 
as the vasoconstrictors, the two acting in harmony maintain the vascular 
elasticity or tone. The chief center or "home office" of the vasoconstrictors 
is in the upper portion of the medulla, besides which there are secondary 
centers or "substations," so to speak, in the spinal cord. In health, the med- 
ullary center in all probability carries on the function independent of the 
accessory spinal centers, but experiments have shown that when this chief 
center has been obliterated, the secondary spinal centers eventually pick up 
the work and maintain the tone of the vessels, — a very important point to 
remember.* With these physiologic and anatomic data in mind, the con- 
sideration of shock may be continued. 

Causes of Shock. — Trauma. — Surgical shock is associated with various 
forms and degrees of trauma. In using the word trauma, I do not neces- 
sarily mean a single or severe injury alone, but I desire to include a series or 
multiplicity of minor injuries, which collectively induce this condition. 
Shock may be produced by the mangling of a large surface of skin, the 
rough handling of tissues during an operation that is associated with some 
hemorrhage, exposure and duration of operative procedures, and the de- 
pressing effects of the anesthetic. So that in operations rapidity of work 
compatible with thoroughness, gentle manipulation of the tissues, protection 
from exposure to the extremes of temperature, careful hemostasis and the 
use of as little anesthetic as possible, all tend toward the conservation of the 
patient's resources. 

Hemorrhage enters into the etiology of this condition to a very great 
extent and as Crile puts it, "a long bloodless operation is much less serious 
than a short and bloody one." 

Tissues Involved — Innervation of Part. — Injury to, or operative interfer- 
ence on certain tissues, are more liable to produce shock than the same 
causes on other tissues, — all depending on the amount of innervation to the 
traumatized area. 



* Some authorities deny the presence of vasodilators, claiming that the vasocon- 
strictors accomplish both functions by contraction and relaxation. This probably is the 
true hypothesis, because other muscular structures do not have two innervations, — one 
to relax and the other to contract. 



Theory of Shock 121 

Crile's observations indicate that the greater the nerve supply of any part, 
the greater is the liability to shock. In short one of the chief factors in the 
production of shock is the excessive or prolonged stimulation of nerve tissue. 

Personal Equation of the Patient. — This will have an important bearing 
in the production of shock. The aged, with the usual degenerative changes, 
naturally are susceptible to shock. The highly nervous individual who is 
always in a state of hyperesthesia is a fit subject to invite this condition. 
Subjects of the different sedentary occupations, individuals with overtaxed 
brains and lack of normal exercise, are predisposed. 

Psychic Causes. — These are well-known factors in the production of 
shock, especially in accident cases. The subject may think an injury is 
inevitable, possibly a fatality. He instantly becomes unconscious; no injury 
may have been received, no pain suffered, yet the impression made on the 
cerebral centers has so disturbed the centers in the medulla as to produce 
shock : fear being the predominant factor. Death can occur in this manner. 

The fear of an anticipated operation often acts as a predisposing cause. in 
the production of shock, and accounts for this condition developing after 
operative procedures of practically minor importance. 

The Theory of the Production of Shock. — After a severe or prolonged 
impression is made on the nervous system by physical or psychical causes, 
a paresis or exhaustion occurs in the vasomotor center in the medulla. The 
millions of these small nerve filaments which surround the blood-vessels 
cease to functionate to a greater or less extent, the tone of the vascular 
system is lost proportionately, and the former vessels which were capable of 
dilatation and contraction now become more or less helplessly relaxed, and 
their caliber enormously increased. They are no longer blood-vessels capable 
of functionating, — simply channels of blood, the current of which is becom- 
ing less and less. Sooner or later if this condition is not relieved, the 
circulation if it may be termed such, becomes a matter of gravity tending in 
the direction of least resistance — toward the large abdominal vessels (the 
splanchnics) which alone are capable of holding in their relaxed state the 
entire amount of blood in the body. The heartbeats are becoming more 
feeble and faster every moment, because there is not sufficient fluid within 
its cavity to stimulate its action. The blood-pressure is dropping in propor- 
tion to the feebleness of the heart's action. The respiration is sighing and 
shallow, due to the fall in blood-pressure around the centers controlling this 
important function. The face loses its normal color and cold, clammy 
perspiration is present : the former the result of the blood draining to the 
large abdominal vessels, the latter due to the loss of nerve influence. 
The general muscular structure is relaxed, the cheeks shrunken, the eyes are 
deep set, the bridge of the nose is pinched and more prominent, the extremi- 



122 Treatment of Shock 

ties are cold and lifeless. The body-temperature falls below normal. Pain 
is absent, and the centers of sensation are abolished because of lack of blood- 
pressure. All the vital processes are slowly ebbing away, until the patient 
succumbs. There are other theories which have from time to time been 
enunciated as to the philosophy of shock, but none that are as well founded 
or which have stood the clinical test. 

Such are the phenomena of shock in its fatal form. Various shades of 
the picture are seen, from the simple sincope or faint that is caused by a 
temporary cerebral anemia, to the fatal form which I have tried to depict. 

A Comparison Between Shock and Hemorrhage. — A careful analysis of 
this subject must impress the student that the symptoms of shock closely 
resemble those of hemorrhage — in fact, frequently it is impossible to differ- 
entiate shock from concealed hemorrhage. The pallid face of shock has its 
counterpart in hemorrhage ; the rapid pulse in the one, is also seen in the 
other; the sighing respiration, cold extremities, and bluish-colored nails are 
common to both; air hunger is present in shock as well as hemorrhage; 
blood-pressure falls alike in either condition. Both conditions generally arise 
immediately after operative measures yet they may occur later {delayed 
shock). This is the natural sequence, for in shock the blood although normal 
in amount is insufficient to fill the greatly dilated vessels, zvhile in hem- 
orrhage the vessels although of normal caliber have not sufficient blood 
within to fill them. Shock is really blood-vessels bleeding within themselves, 
zvhile hemorrhage is a blood-vessel leaking outside. In shock the large 
abdominal veins act as reservoirs to receive the gravitating and practically 
currentless blood, while in hemorrhage the tissues without act as basins to 
retain the leaking current. 

Treatment of Shock. — This can be divided into three parts — 

(1) Prevent further shock. 

(2) Support the circulation. 

(3) Maintain rest. 

The Prevention of Further Shock. — This will depend on the cause of the 
condition. If the patient is undergoing an operation and there is a rapid 
fall of blood-pressure the anesthetic should be withdrawn, and if possible 
the operation postponed for future completion. If an accident has caused 
vasomotor paresis a small amount of morphin is administered hypoder- 
matically in an endeavor to block any further impression on the circulatory 
centers. 



Treatment of Shock 123 

Support the Circulation. — This may be accomplished in three ways — 

(1) By transfusion. 

(2) By the introduction of solution adrenalin chlorid alone into the circu- 
lation, or in connection with an intravenous infusion. 

(3) By mechanical means. 

Transfusion. — This is the ideal. No more efficient means is known, or 
possibly ever will be; every indication is met by its use. The effects are 
immediate, the patient who is moribund is instantly restored to practically 
a normal condition and remains so. The only disadvantage possibly that 
can be attributed is the inability always to obtain a donor. (See lecture on 
"Transfusion — Infusion.") 

Solution of Adrenalin Chlorid — Intravenous Infusion. — This is adminis- 
tered directly into the vein (dose 15 m.). A better plan, however, is in com- 
bination with a saline infusion (3 1 to pts. 2) because two benefits are 
derived: (1) The stimulating effects of the adrenalin are immediately 
manifested. (2) The volume of infusion fills the calibers of the relaxed 
vessels. (See lecture on "Transfusion — Infusion.") Adrenalin solution, as I 
have said, must be given directly into the vein to accomplish its purpose. If 
administered subcutaneously its effects are purely local, if by the mouth the 
drug never reaches the circulation. 

The hypodermatic employment of strychnin sulphate may be tried. The 
administration of nitroglycerin is absolutely against common sense : this 
drug is a vasodilator and the pathologic condition we are dealing with is one 
of exaggerated dilatation. What can therefore be accomplished except 
harm? Ergot has been tried frequently with negative results. So we must 
not waste valuable time waiting for effects from these drugs. 

Mechanical Means. — Following the method of Crile, the circulation may 
be mechanically supported by applying folds of cotton wadding to the 
extremities, and a large compress from similar material over the abdomen, 
which are held in place by snugly applied bandages. (I have on several 
occasions utilized a small pillow doubled on itself for the abdominal com- 
press, maintaining it in position in a like manner.) Far better than this, but 
unfortunately very seldom at hand when needed, is the Crile pneumatic suit, 
which envelops the entire body to the neck. After being adjusted it is 
inflated with air to the desired pressure. This accessory affords the advan- 
tage to the operator of increasing or diminishing at will the pressure exer- 
cised on the vessels. The philosophy therefore which has been given relative 
to the support of the circulation is this : The relaxed blood-vessels are filled 
either with blood derived from another or normal saline with adrenalin 
chlorid, both of which will cause an increased pressure from within, while 



124 



Treatment of Shock 



the compresses that have been made, or the pneumatic suit which has been 
adjusted, tend to constrict the caliber of the vessels from without. 

Another important auxiliary in aiding the impoverished circulation is 
position. The foot of the bed should be elevated (about 30°) to encourage 
cerebral circulation and assist blood-pressure around the vital centers, at the 
same time applying artificial heat. (See illustration XXXVI.) 



Rest. — Both mental and physical rest are essential elements in the treat- 
ment of shock. To accomplish the latter, the patient should be put to bed in 




m 



% 



Illustration XXXVI 

Shock Bed. — Note the simple construction of the elevator. The bed covers are 
turned back to show the draw sheet and hot-water bottles. Observe the towels 
at the head of the bed for such emergencies as vomiting-, etc. 



position suggested, all unnecessary noise avoided, and excitement reduced to 
a minimum. If conscious, and aimlessly tossing in bed, the administration 
of morphin hypodermatically is indicated. Dissolution being imminent, 
employ cardiac massage and use artificial means to stimulate the respiration. 
(See lecture on "Anesthesia," section "Accidents.") 

Nurse's Duties. — 

(1) Immediately notify the surgeon. 

(2) If the patient is in the Fowler position following an operation, lower 
the head and elevate the foot of the bed to an angle of about 30°. 



Treatment of Shock 125 

(3) If an accident case accompanied with great suffering, administer a 
small dose of morphin hypodermatically to block the pain, and place in a 
similar position. 

(4) Apply artificial heat. 

(5) Support the circulation by mechanical means. 

(6) If transfusion or intravenous infusion is to be employed prepare the 
sites and sterilize the necessary instruments. 

(7) Arrange personal toilet and assist surgeon in carrying out step six. 

(8) Whichever method is employed, keep the exposed blood-vessels moist- 
ened with warm saline solution during the entire process. 

BIBLIOGRAPHY. 
Keen's Surgery — Geo. W. Crile, M. D. 



LECTURE XIII 

HEMORRHAGE 

By the term hemorrhage is meant the loss of a large amount of blood 
from the vessels. I shall limit this condition to a break in the vessel- wall, 
the result of trauma or operative measures, and not include other causes 
which do not concern you as surgical nurses ; except to mention that peculiar 
condition known as hemophilia, which is "a tendency that certain individuals 
possess to bleed on the slightest provocation" (Rudolph Matas, M. D.), the 
cause of which idiosyncrasy is unknown. 

Classification. — Depending on the kind of vessel from which the escape of 
blood takes place, hemorrhage is divided into 

(1) Arterial. 

(2) Venous. 

(3) Capillary or parenchymatous. 

Arterial Hemorrhage. — "When the hemorrhage is from an artery the color 
of the blood is bright red and the flow, as a rule, pulsating and active. 

Venous Hemorrhage. — The blood from the veins is dark, because it has 
eliminated its oxygen to the tissues. The current is passive or slow and 
there is no pulsation. 

Capillary Hemorrhage. — This appears in the tissues without any definite 
vessel of origin being involved. There is no characteristic color, no pulsa- 
tion ; oozing is seen of an active or passive character. 

Concealed Hemorrhage is where the bleeding is confined within the body, 
and is not visible. 

Primary Hemorrhage. — By this term is understood the escape of blood 
immediately following the break in the vessel-wall. 

Secondary Hemorrhage. — This term implies that a hemorrhage has super- 
vened some time after an injury was received or operative interference. 

Resume of the Physiology of the Blood. — Besides the physiology which I 
have spoken about concerning certain constituents of the blood and the part 

(126) 



Pathology of Hemorrhage 127 

this fluid plays in natural resistance, it would be well to briefly state some of 
its other functions. 

Blood is the chief factor in the physiology of vital processes. It is the 
medium through which oxygen is supplied to the tissues. It is the carrier 
of nutritive material derived from the food to the various parts of the 
economy. It is a factor in preserving body-temperature. The vasomotor 
center, the center of respiration, and other vital centers, depend on the 
volume and character of the blood-current for their functionating capacity. 
The amount of blood in the coronary arteries and in the cavities of the heart 
is the primary factor of cardiac physiology, — in short the blood is the 
primary requisite of life on which the various vital phenomena are 
dependent. 

The amount of blood in the body is about one-fourteenth to one-twelfth 
of the body weight. Death is practically inevitable if one-half of the total 
amount in the economy is lost at one time, however, much larger quantities 
may be wasted if the hemorrhage is gradual, — that is to say, if the escape 
covers a long period of time, — say weeks, because Nature is afforded an 
opportunity in which to replenish the depleted system; for as Crile says, 
''the blood is, of all the tissues, most rapidly and completely repaired and 
regenerated." 

The Pathology of Hemorrhage. — Death from hemorrhage is not due to 
the loss of the elements of the blood, but to the insufficient amount to 
maintain blood-pressure. The diminution of blood in the vessels causes an 
increased demand on the vasoconstrictor center in the medulla, whose func- 
tion is to regulate the caliber of the vessels in proportion to the amount of 
blood within. The greater and more sudden the hemorrhage, the greater 
and more severe will be the demand on this center to constrict the bore of 
the vessel to correspond to the diminished amount of blood. If the hem- 
orrhage continues, the vasoconstrictor center ceases to functionate — becomes 
exhausted, because of the excessive demands made on it. Constriction of 
the caliber of the vessels is then lost, the entire vascular system relaxes, and 
blood-pressure drops; shock Jias been engrafted on an economy already 
depleted of blood! 

The existing phenomena therefore are : 

(1) Actual loss of blood. 

(2) Gradual decrease in blood-pressure. 

(3) Vasomotor paresis. 

(4) Constriction of caliber of vessels abolished. 

(5) Blood-pressure reduced to a minimum. 

Symptoms of Hemorrhage. — The constitutional symptoms of hemorrhage 
are very similar to those of shock. As I have stated before, when the bleed- 



128 Treatment of Hemorrhage 

ing is of the concealed variety a differential diagnosis is sometimes impossi- 
ble. (See lecture on "Shock.") On the other hand, hemorrhage other than 
the concealed class carries with it its own objective sign — the presence of 
blood. 

Treatment. — The treatment of hemorrhage may be divided into two 
parts — 

(1) The local means employed to arrest the flow. 

(2) The general measures utilized to offset the deleterious effects on the 
economy. 

The Local Means Employed to Arrest the Flow. — The first essential in 
the control of hemorrhage is the ligation of the vessel. This cannot always 
be accomplished because the injury may have been received in such a loca- 
tion of the body or under such unfavorable conditions as to preclude an 
immediate ligation, and to necessitate the transferring of the patient to more 
suitable surroundings to accomplish the necessary surgical interference. 
Under such circumstances reliance must be placed on other means than 
ligation of the vessel. 

Posture. — This becomes an expedient in assisting to control the escape of 
blood. Elevation of a bleeding area tends to lessen the force and amount of 
the arterial current, and at the same time favors the return of blood to the 
heart. It makes no difference what part of the body is thus elevated, this 
same rule holds true. If the pelvis is the location from which the hem- 
orrhage is occurring the "head-down" position (45°) will lessen the leak, 
and possibly check the flow, depending of course on the size of the injured 
vessel. If the escape of blood is from an extremity the raising of such a 
member to a perpendicular with the body will assist in retarding the escape ; 
however, bleeding from an arm or leg can be controlled by better mechanical 
means, as will be described later. In hemorrhages from any portion of the 
head, neck, or throat, the same rule applies as to elevation, but it cannot be 
carried to the same extent as in other portions of the body, because in doing 
so such an anemic (bloodless) condition of the vital centers may be pro- 
duced as to cause a complete cessation of their function. This leads to 
another statement : in cases of impending dissolution from the loss of blood, 
the elevation of the pelvis ("head-down") 30° to 45° is indicated; the object 
to conserve the remainder of the blood around the cerebral and medul- 
centers in an attempt to prolong life until remedial efforts can be 
administered. 

Pressure. — This may be applied either directly on the bleeding part, or 
indirectly over the course of the vessel, either of which is an efficient means 
of controlling hemorrhage until ligation can be accomplished. 



Treatment of Hemorrhage 129 

Direct Pressure. — This is accomplished in a variety of ways; the simplest 
form is by pressure of the hand at the site of injury; other forms of pres- 
sure are obtained by compresses, tampons, instruments, and ligatures. 

Indirect Pressure is obtained by utilizing the Esmarch tourniquet, which 
is a strong rubber band of various lengths, and can be purchased anywhere; 
or an equally efficient substitute may be made by utilizing rubber-tubing. 
(See illustration XXXVII.) The tourniquet is adjusted at a point above the 




Illustration XXXVII 
Esmarch Tourniquet 



bleeding area, and its application made by stretching with each turn of 
the circle.* 

In emergency cases, removed from hospital service, where the usual rub- 
ber tourniquet is not at hand, clothesline, fountain-syringe tubing, sus- 
penders, or even a handkerchief may be tied around the bleeding member, 
and the necessary amount of tension made by passing a lever beneath the 
improvised tourniquet and twisting it, — the Spanish windlass. 

Heat. — This is utilized frequently to check capillary hemorrhage, by 
wringing sponges out of very hot water and applying them to the bleeding 
area, being assisted by direct pressure. The employment of boiling water 
as recommended for this purpose should not be seriously considered, as this 
may cause sloughing of the tissues. 



* In cases of hemorrhage of forearm or leg, the tourniquet must be applied above the 
elbow or knee. 



130 Treatment of Hemorrhage 

These expedients are only temporary for the control of hemorrhage, the 
desideratum is the direct ligation of the bleeding vessel, and this should be 
done whenever possible. 

The General Measures Utilized to Offset the Deleterious Effects on the 
Economy. — The conservation of the remaining portion of the blood in the 
body is accomplished by depleting or "milking" the blood from the extremi- 
ties toward the trunk and maintaining it there for a limited period of time, 
the steps of which are as follows : 

Method One. — 

(1) Elevate the member. 

(2) Stroke the member from the digits (fingers or toes) toward the 
trunk until the part becomes pale in comparison with its fellows. 

(3) Apply a tourniquet around the limb as close to the trunk as possible. 
All four members may be thus treated. 

A more efficient way is : 
Method Two. — 

(1) Elevate the member. 

(2) Apply a rubber bandage to the limb with spiral turns from the distal 
extremities toward the body, thus forcing the blood ahead of the bandage 
into the large abdominal vessels. 

(3) Apply a tourniquet close to the trunk to prevent the return of blood. 

(4) Remove the bandage. 

The first method is applicable to emergency cases occurring outside of 
hospital service. 

Compensation for Loss of Blood. — The most efficient way to accomplish 
this is by means of transfusion. The difficulty however of obtaining the 
blood of another makes it an expedient which cannot always be utilized. 
Intravenous infusion of normal saline combined with solution adrenalin 
chlo^d becomes then the second choice. The advantages of this solution 
are the absence of complicated mechanism, and the facility with which it 
may be administered. The disadvantages however are the following: 

(1) Its stimulating action is of short duration. 

(2) If a sufficiently large amount is infused it reduces the specific gravity 
of the blood, and hence permits the transudation of the fluid through the 
coats of the vessels. 

Administration of Water by the Mouth. — In severe cases of hemorrhage 
thirst is insatiable, — the patient continually demands fluids. The drinking 
of water does little or no good, as absorption is at the minimum and the 



Treatment of Hemorrhage 131 

sufferer will sooner or later eject the contents of the stomach. This is men- 
tioned because you should not be deceived with the idea that restoration of 
the body-fluids is taking place through this medium. 

Rest. — It is hardly necessary for one to allude to this important factor. 
Every exertion on the part of the patient increases the outflow of the blood. 
It is therefore your duty to maintain the sufferer in complete rest. 

Conserving Body-temperature. — This must be accomplished by means of 
artificial heat, using warm-water bottles, etc. 

Medicinal Agents. — If the patient is conscious, suffering pain, and aim- 
lessly tossing, a small dose of morphin hypodermatically is indicated. 
Besides quieting the patient, its effects on the circulation are not to be 
underestimated. 

Employment of nitroglycerin, a vasodilator especially of the veins, is 
positively harmful because these vessels are already proportionately too 
large for the amount of blood in the economy. 

Alcoholic and other stimulants are contraindicated while hemorrhage is 
occurring. — What good can be obtained by stimulating a heart to force more 
blood from a leaking vessel? The condition is changed, however, when 
the flow is stopped; then stimulation is indicated, the various forms of alco- 
hol should be administered by the mouth, and stimulating rectal enemata 
given of brandy and strong coffee in saline solution, possibly strychnin 
hypodermatically. 

Local Astringents. — The long list of styptics (drugs used locally for the 
arresting of hemorrhage) which are advised in text-books on materia 
medica have little if any effect. Solution adrenalin chlorid (1:1000) 
applied to the bleeding area is efficient in venous oozing, but has no value 
in arterial hemorrhage. 

MonseVs Solution of Iron (liq. ferri subsulphatis) is the best of this class 
of drugs, — it certainly will arrest venous hemorrhage, but the slough it pro- 
duces in the tissues prohibits its employment except as a last resort. One 
of the most devastating hemorrhages I ever witnessed followed an opera- 
tion for tonsilectomy. The patient was practically exsanguinated. Every 
known method of arresting the flow had been tried, pressure made with 
gauze moistened in solution adrenalin chlorid, the pillars of the tonsils 
were sewed together, purse .string sutures were taken around the base of the 
tonsil, pressure on the carotids, elevation of the head was carried to an 
extent to produce anemia of the cerebrum with its accompanying collapse, — 
all with negative results. As a last resort Monsel's solution of iron was 



132 Treatment of Hemorrhage 

applied with instantaneous relief. A necrotic slough followed as usual, 
lasting two weeks. 

Nurse's Duties. — 

(1) If after operative procedures in the abdomen the pulse becomes 
weaker and faster, with a corresponding drop in temperature, whether 
there is discernible hemorrhage or not, summon the surgeon. 

(2) If hemorrhage is discovered following an operation on an extremity, 
or on a superficial area of the body, arrest the same with a tourniquet, or 
remove outer dressings and make pressure on the bleeding area until sur- 
gical assistance is obtained. 

(3) If compression is impossible, elevate the bleeding area whenever 
practical, thus placing the part in a position opposed to gravity. 

(4) If a fatality seems imminent, irrespective of the location of the hem- 
orrhage elevate the foot of the bed 30° to 40° in an endeavor to maintain a 
blood-supply to the brain. 

(5) Supply artificial heat to maintain body-temperature. 

(6) Conserve all blood possible by milking extremities, and adjusting 
tourniquets close to the trunk. 

(7) Prepare for transfusion or intravenous infusion of normal saline 
solution combined with adrenalin chlorid. (See lecture on "Transfusion — 
Infusion.") 

(8) Quiet nervous restlessness by hypodermatic injections of morphin 
sulphate gr. }i to gr. % in the absence of proper authority. 

(9) Hemorrhage being checked, stimulation is indicated, and orders will 
be given for the same. 

The above rules are quite as applicable to emergency cases as to accidents 
following postoperative interference. 

BIBLIOGRAPHY. 
Keen's Surgery — Rudolph Matas, M. D. 



LECTURE XIV 
WOUNDS, CONTUSIONS, AND ABRASIONS 

By the term wound is understood a violent solution of the continuity of 
the soft tissues of the body. Inasmuch as a wound may be produced in 
different ways, give various appearances to the eye, and cause dissimilar 
pathologic conditions, they are designated accordingly : 

Classification. — 

(1) Incised. 

(2) Contused. 

(3) Lacerated. 

(4) Punctured or stab wounds. 

(5) Gunshot wounds. 

(6) Open surgical wounds. 

(1) An Incised Wound is one made by a sharp instrument, as a knife or 
the edge of broken glass. The lips of such a wound are clean cut, per- 
mitting of smooth approximation. 

(2) A Contused Wound is one in which the edges are contused, crushed, 
and ragged. The injury extends to the surrounding tissues. It is produced 
by blows from clubs, falling timber, or stones, hence the edges cannot be 
smoothly coaptated. The adjoining tissues are partially devitalized because 
the blood-vessels supplying the parts have been damaged. 

(3) A Lacerated Wound is one in which large surfaces have been 
mangled and tissues torn apart — such results as you would expect to see 
from the clazvs of an animal or coming in- contact with the gears of ma- 
chinery, or railroad accidents. The margins of such a wound are irregular 
— indeed tissue is often wanting to fill in the gap. This wound is of greater 
severity than the contused, simply because the surrounding area has been 
more damaged. 

(4) Punctured or Stab Wounds have been very aptly described as having 
but "slight opening in the integument, with comparatively great depth of 
penetration." — (Crile.) Such injuries as are caused by sharp-pointed 

(133) 



134 Repair of Wounds 

knives, bayonets, or nails. These wounds are dangerous, inasmuch as 
they cannot be examined carefully nor thoroughly cleansed. 

(5) A Gunshot Wound, according to Senn, is one caused by any missile 
projected by an explosive agent. The characteristics of such a wound of 
course vary with the projectile. The entrance of a gunshot wound pro- 
duced by a lead bullet is smaller than the exit. With the modern steel- 
jacketed bullet the two wounds are generally of equal size. Occasionally, 
however, the wound of exit may be so diminutive as to be overlooked. 
Another peculiarity of a gunshot wound produced by a lead bullet of slow 
velocity, is that it carries dirt and fragments within the tissues, while the 
modern high-speed jacketed bullet is much less liable to do so. The latter 
appears to sterilize the tract it has made. 

(6) An Open Surgical Wound. — Occasionally when a large amount of 
tissue has been removed by the surgeon and the edges cannot be coaptated, 
or it is presumed that infection is present, the wound is left open to afford 
better drainage. It may be termed an open surgical wound, because it can- 
not be identified with any of the foregoing. You will note that it is not an 
incised wound because the edges are not, or cannot be coaptated ; it cannot 
be classified in the contused variety, since there is no contusion of the tis- 
sues ; nor is it mangled, to come under the head of lacerated wound. 

You must not confound a poisoned with an infected wound, — the former 
is the result of the entrance of some chemical poison, such as the stings of 
insects, reptiles, etc., while an infected wound is one in which bacteria have 
gained a foothold. 

A contusion is really a subcutaneous wound, — the skin itself is not 
broken, but the tissues beneath have suffered injury. Occasionally a vessel 
of considerable size is wounded, or several minor vessels, and an extravasa- 
tion of the blood occurs, forming a clot beneath the tissue, which is called 
a hematoma. 

An abrasion is simply a denuded surface. 

Repair of Wounds. — The principles involved in wound repair are the 
same in all classes, the only practical difference being the amount of such 
repairative process. It has been customary, in order to bring before the 
mind's eye certain factors dealing with wound healing, to describe three 
processes, viz., healing by the first, second, or third intention. 

Healing by the First Intention, or Primary Union. — This can only take 
place when the surfaces of the wound can be nicely coaptated ; it is therefore 
in the incised variety of injury that this form of healing generally occurs. 



Repair of Wounds 135 

Process of Repair. — Immediately after a wound takes place there will be 
more or less blood poured into the cavity. Whatever care or means is made 
to remove this, there will still remain some microscopical clots. 

The first step in the process of repair is a dilatation of the blood-vessels 
supplying the part. The blood-current is retarded, and an exudation of 
serum, fibrin, and red and white blood-corpuscles takes place. If the sur- 
faces of the wound are nicely coaptated agglutination occurs as a result of 
the elements which have escaped from the vessels. The leukocytes dispose 
of the microscopical clots which were left, assist in making away with the 
dead-tissue cells, and with the aid of the opsonins derived from the blood- 
serum devour any pathogenic bacteria which may be present. Sooner or 
later epithelial and connective-tissue cells proliferate on the raw surfaces, — 
oval in shape at first, not partaking of the characteristics of the parent cell. 
Sprouting from the capillaries, newly formed blood-vessels appear on the 
surface, forming loops between the new epithelial and connective-tissue 
cells. If the wound were pulled apart, so as to permit an inspection of its 
depths, a granular appearance would be observed, due to the proliferation 
of cells and the newly formed blood-vessels. This is known as "granula- 
tion tissue!' The connective-tissue cells soon begin to change their shape ; 
they become more elongated until they dovetail or interlace with each other. 
A process of contraction begins. The majority of the newly formed blood- 
vessels are obliterated by this process of pressure. The contraction con- 
tinues until a dense pale tissue is formed. The denser this tissue the less 
will be its vascularity, because the greater will be the obliteration of the 
vessels. This is termed a cicatrix or scar tissue. Healing by the first inten- 
tion is accomplished, which requires a period of from seven to ten days. 
This result can only be obtained when the tissues have suffered the smallest 
amount of trauma and the wound edges are coaptated, and when infection 
has not occurred or the tissues have not been devitalized by the abuse of 
strong antiseptics. Healing by the first intention, therefore, implies that 
the wound surfaces have been coaptated, and joined together by the min- 
imum amount of scar tissue. 

Healing by the Second Intention — Secondary Union, or Healing by 
Granulation. — This is a similar process to the one just described. The dif- 
ference is chiefly in the quantity of the material required for repair. When 
a certain amount of tissue has been lost the surface and edges of the wound 
cannot be coaptated, so that it is necessary for some "filling in" to take place 
with newly organized material. 

Process of Repair. — The local blood-vessels which have been injured at 
once dilate, the blood-current is slowed, transudation of fibrin, serum, 



136 Repair of Wounds 

leukocytes, and red blood-corpuscles takes place from the vessels, forming 
a serofibrinous exudate on the raw surface. This film of exudation not 
only serves the purpose of protection, but also forms a groundwork for the 
future processes which are about to take place. The leukocytes which 
have appeared on the field are making away with debris, devouring patho- 
genic bacteria and raising the natural resistance of the part, and are per- 
forming the function of phagocytosis, as explained in the lecture on 
"Infection."' 

Following this process (which may be aptly termed Nature's preparatory 
methods") the epithelial and connective-tissue cells begin to proliferate. 
Newly formed blood-vessels from the veins and capillaries appear. The 
epithelium "juts out" from the skin edges toward the center of the wounded 
area. The connective-tissue elements form layer upon layer ; they cover 
the wounded surface and are surrounded by loops of newly made blood- 
vessels, giving a granular appearance. — the so-called "granulation tissue" 
which appears about the fourth day. These cells which were oval at first, 
now become elongated, interlace with each other, and a process of contrac- 
tion begins which obliterates the newly formed blood-vessels interwoven in 
their midst. As this process of contraction continues the vascularity 
diminishes, but the new- formed tissue becomes denser. Scar tissue is thus 
formed. The constant tendency to contract which this new tissue possesses 
develops the many deformities incident to burns. If the area to be covered 
is large the epithelium springing from the edges of the skin is only capable 
of covering a limited zone around the free margins of the wound, leaving 
the center bare. The connective-tissue elements in this nude area continue 
to proliferate above the surface of the skin, and are called prolific granula- 
tions or ''proud flesh.''' In many instances it becomes necessary under these 
conditions to supply epithelium to the central portion. This is accom- 
plished by curetting the excessive granulations and trans plating thin films 
of skin from other portions of the body. — skin-grafting. These small 
islands of transplanted skin form nuclei from which epithelium spreads. 

Healing by the Third Intention. — After the appearance of granulation 
tissue, efforts are made to approximate the edges of the wound by the use 
of adhesive plaster or other mechanical means, preferably after curetting 
the superficial granulations. This can only be done where small surfaces 
are wounded, the object being to lessen the amount of scar tissues on the 
skifi surface, and hasten the process of healing. 

Recapitulation. — I have considered it advisable, although it be repetition, 
to give a synopsis of the various steps in the process of wound repair, a 



General Consideration 137 

careful analysis of which will demonstrate the striking similarity of all 
varieties. 

(1) Dilatation of blood-vessels, slowing of blood-current. 

(2) Transudation of fibrin, serum, and red and white blood-corpuscles. 

(3) Process of phagocytosis occurs, that is the leukocytes with the aid of 

the blood-serum are disposing of dead tissue and pathogenic bacteria. 

(4) Agglutination of wound surfaces (only in healing by first intention). 

(5) Proliferation of oval-shaped connective-tissue and epithelial cells. 

(6) Development of newly formed blood-vessels. 

(7) Formation of granulation tissue, the result of intermingling of the 
newly formed tissue cells and capillaries. 

(8) Tissue cells change their shape, become elongated, and interlace with 
each other. 

(9) A process of contraction begins, obliterating the newly formed blood- 
vessels. 

(10) Contraction produces density of newly formed tissue. 

(11) A cicatrix or scar tissue is developed. 

General Consideration of Wounds. — Hemorrhage. — This depends on 
several factors, chiefly among which is the vascularity of the part injured. 
The richer the blood-supply and the larger the arteries, the greater, of 
course, will be the loss of blood. The kind of wound decides to some 
extent the amount of bleeding. The incised variety as a rule will produce 
a greater hemorrhage than the contused and lacerated, because the clean-cut 
edges of the former allow a freer escape of blood than the crushed ends of 
the latter ; however, secondary hemorrhage is much more common in con- 
tused and lacerated wounds because of the slough which takes place later. 
Hemorrhage is an important factor in the production of shock following 
these injuries. 

The physical condition of the patient is a factor that determines the 
amount of hemorrhage to some extent. The plethoric ('full-blooded') indi- 
vidual will certainly be more apt to suffer severe hemorrhage than the pale 
anemic subject. The patient with hardened arteries bleeds easier and freer 
than one whose vessels are soft and more collapsible. 

Since hemorrhage plays an important part in the production of shock, it 
should be therefore the first consideration in the treatment of wounds. Dur- 
ing an operation the control of bleeding vessels is under the supervision of 
the operator, but in accidental wounds or in postoperative cases, it occa- 
sionally falls to the lot of a nurse to meet the exigency. The healing of a 



138 Pain — Ecchymosis — Rest 

wound to a great extent depends upon the thoroughness of hemostasis, so it 
becomes necessary to pay strict attention to this. 

Pain. — This will depend of course on the part injured, the greater the 
nerve supply the more pronounced will be this symptom. The hyperesthetic 
(oversensitive) patient will suffer physically and psychically more than the 
phlegmatic. The more severe the pain, the longer its continuance ; the more 
nerve tissue injured and the greater the psychic effect, the more liable is the 
patient to shock. In the treatment of accidental wounds the object should 
be to minimize the amount of pain by the use of morphin hypodermatically, 
which will in no way interfere with the administration of an anesthetic, if 
such becomes necessary later. 

Ecchymosis ("Black and Blue"). — In nearly all classes of wounds ex- 
cepting possibly the incised, there will be more or less extravasation of 
blood which discolors the surrounding area — the so called "black and blue" 
or technically, ecchymosis. The more superficial this extravasated blood, 
the sooner will ecchymosis make its appearance; the deeper the extravasa- 
tion, the more delayed will be this symptom. It is for this latter reason 
that ecchymosis is occasionally not apparent for several days after an acci- 
dent. The presence of this symptom indicates the rupture of vessels 
beneath the skin to a greater or less depth, and to some extent is an indica- 
tion of the amount of injury the part received. Such extravasated blood is 
removed by the action of the leukocytes, and possibly to some extent by 
direct absorption. 

Rest — General and Local. — The patient has suffered not only a local in- 
jury, but an impression has been made on the nervous system, an impres- 
sion that is proportionate to the injury, and susceptibility of temperament. 
In all severe wounds the patient should be put to bed as soon as possible. 
Local rest is indicated because it favors a more rapid healing, and limits 
infection. If such a complication occurs the part should be splinted if prac- 
tical so as to prohibit muscular action. 

Cleanliness. — It has been said the final result of wounds, and even life 
itself, depends upon the thoroughness of first-aid treatment. For this 
reason there is no excuse for not being surgically clean in the treatment of 
wounds whether surgical or accidental. Great stress is laid on the prepara- 
tion of the field for operation, while carelessness is frequently witnessed in 
the cleansing of an accidental wound. Deviation from the strict rules of 
asepsis is not warranted because a wound has been received under septic 
conditions — in fact, the reverse is true. Such wounds require greater care 
to prevent infection. The part is laboring under great disadvantages. I 
may mention in this connection, as first shown by Crile, that the oil- 



Treatment of Wounds 139 

besmeared hands of machinists and railroad men when injured are really 
more aseptic and require less care in their surgical preparation than the 
hands of workmen soiled with the dust and dirt of the street. 

Treatment of Wounds. — In order to give a clear idea of the duties of a 
nurse in the treatment of wounds I shall divide these injuries into two 
classes — (1) Aseptic and (2) Infected Wounds. 

(1) Aseptic Wounds. — There is really no such condition as a wound 
free from pathogenic bacteria, but wounds that are made during an opera- 
tion with everything sterile connected with the technic should be considered 
aseptic. It is the aim of the surgeon to make incisions in such a manner 
that the edges of the wound will nicely coaptate (incised variety) so as to 
obtain healing by the first intention — that is with as little scar tissue as 
possible. In fact, I should say an incised wound however caused (especially 
where cosmetic effects are necessary) should be treated as aseptic, until 
infection proves it to the contrary. Occasionally, however, where large 
areas of tissue have to be removed, it is impossible to coaptate the edges of 
the wound because of the excessive tension this will produce, so that a raw 
surface is left to heal by the second intention, — the open surgical wound. 

Aseptic Incised Wounds — Principles Involved. — 

(1) Complete control of hemorrhage. 

(2) Thorough cleansing of the wound of all blood-clots. 

(3) Coaptation of the wound by sutures. 

(4) Introduction of drain, if wound is deep and fear is entertained of 
capillary oozing. 

(5) Application of sterile dressings, held in place by bandages. 

(6) Rest. 

Aseptic Open Surgical Wounds — Principles Involved. — 

(1) Complete control of hemorrhage. 

(2) Thorough cleansing of the wound of all blood-clots. 

(3) Protect the raw surface by several layers of sterile gauze. 

(4) Approximate the edges by the use of adhesive strips placed over the 
gauze to relieve tension of the wound. 

(5) Complete the dressing with cotton-gauze pads held in place with a 
bandage. 

Nurse's Duties. — 

(1) Frequent inspection of the outer dressings for the first twenty-four 
hours to ascertain if there is any secondary or postoperative hemorrhage. 

(2) If such is the case immediately notify surgeon. 

(3) Rise in temperature and pulse rate occurring from the fourth to the 
seventh day is indicative of infection. Call surgeon's attention to the same. 



140 Treatment of Wounds 

Change of Dressings — Aseptic Incised Wounds. — The drain, if any has 
been used, is removed in twenty-four or forty-eight hours, following which 
no change in dressing will be necessary, until convalescence is established 
and the sutures are removed after having served their purpose. 

Aseptic Open Wounds. — A change of dressings is advisable about the 
sixth or seventh day to ascertain the condition of the granulation tissue. If 
this is progressing favorably, the dressings need only be renewed every 
fourth or fifth day. 

Necessary Equipment. — 

(1) Irrigator filled with sterile water. 

(2) Hydrogen dioxid in a sterile glass. 

(3) Kelly pad (sterilized). 

(4) Tray containing one pair of scissors and dissecting forceps 
(sterilized). 

(5) Ward dressing outfit, adhesive plaster, rubber tissue. 

(6) Dry sterile gloves (dry gloves are easier adjusted). 

Steps of Technic — Nurse's Duties. — 

(1) Nurse prepares her surgical toilet (omit gloves). 

(2) Remove outer dressings from patient excepting the gauze adherent to 
the wounded surface. 

(3) Arrange sterile towels around the field to prevent contamination from 
bedclothing, etc. 

(4) Place Kelly pad under the field and arrange for drainage. 

(5) Assume gloves and begin the dressing 

(6) Moisten the adherent gauze with hydrogen dioxid to soften and per- 
meate the crusts. 

(7) Irrigate with sterile water until the adherent gauze is detached. No 
force is permissible in the removal of a dressing as in this way granulation 
tissue is damaged and an opportunity afforded for infection. The presence 
of a healthy granulation tissue indicates that Nature has thrown a barrier 
between the deep tissues and external infection. This barrier is therefore 
to be preserved intact. 

(8) Apply sterile dressings to the wound, held in place with adhesive 
straps, followed if necessary by the use of a bandage. 

Complications. — 

(1) If on inspection the granulations appear pale and anemic the surgeon 
will order some stimulating application such as balsam of Peru, or carbolic 
acid lightly mopped over the surface and immediately neutralized with 
alcohol. 

(2) If the epithelium has been unable to cover the denuded area and 
prolific granulations ("proud flesh") are present, the surgeon will curette 



Removal of Stitches 141 

the surface and perform skin-grafting. In which case cover the field with 
perforated oiled silk or strips of this material used shingle-fashion. This 
affords a better protective for the outgrowth of the epithelium than gauze, 
in fact, whether skin-grafting is resorted to or not, rubber tissue forms the 
best protection after the establishment of healthy granulations. 

(3) If the wound be of the open surgical variety and shows a tendency 
to gap, or its edges pull apart, after the sterile-gauze dressing is applied, an 
endeavor should be made to approximate the edges and relieve tension by the 
use of adhesive straps. 

(4) If between the fourth and seventh day in an incised wound, there 
is a rise in temperature and pulse rate, associated with pain in the region of 
the wound, inspection is at once indicated. If infection is present remove 
stitches to permit of drainage and treat the injury like any other infected 
wound 

Removal of Coaptating Stitches. — When sutures have served the purpose 
for which they were used it is necessary to remove them (generally in about 
eight or ten days), especially if they are non-absorbable. I desire to impress 
on you that it is just as essential to carry out an aseptic technic in this con- 
nection as though a more important operation was to be performed. Fre- 
quently infection occurs at this time from carelessness. 

Necessary Equipment. — 

(1) 1 pair of sharp-pointed scissors and dissecting forceps (sterilized), 

(2) Sterile glass of hydrogen dioxid. 

(3) Alcohol or Harrington's solution. 

(4) Sterile towels. 

(5) Dressings. 

(6) Wipe sponges. 

(7) Gloves. 

(8) Adhesive plaster. 

Steps of Technic. — Steps 1, 2, 3, 4, and 5 are the same as have been given 
when describing the technic of "Change of Dressings." 

(6) Saturate a piece of gauze with alcohol or Harrington's solution and 
lay over the stitches for one or two minutes. 

(7) With the aid of dissecting forceps pull one side of the stitch upward, 
cut the same as close to the skin as possible, then remove the suture. 

(8) Protect the stitch holes by applying sterile-gauze dressings, held in 
place with adhesive straps. 

Infected Wounds. — Infection has been defined thus : "When bacteria suf- 
ficient in number or virulence to overcome the natural resistance have gained 
entrance into the economy it is infected." I also told you that the symptoms 



142 Infected Wounds 

of this condition were heat, redness, swelling, pain, and pus — the culmination 
of local infection — so that when on inspection these signs are present in a 
wound, you know infection has occurred. 

The results of Wound Infection are — 

(1) Greater destruction of tissue. 

(2) Longer period of time required for repair. 

(3) A possibility of general infection due to absorption of bacteria. 

Infected wounds do not heal by the first intention. The process of repair 
is consummated by replacement with granulation tissue: the second, or 
third intention. Contused or lacerated wounds should always be considered 
infected. The surrounding area has been more or less devitalized. They 
are always of accidental origin occurring among environments which are 
not conducive to asepsis. 

Infected Wounds — Principles Involved. — 

(1) Free drainage. 

(2) Arrest of further bacterial invasion by the strictest antiseptic technic. 

(3) Rest. 

Drainage. — If the wound is of the incised variety, and its surfaces have 
been coaptated with sutures in the hopes that healing by the first intention 
would be obtained, these should at once be removed to allow the free escape 
of pus, and the cavity carefully washed with a very mild warm antiseptic 
solution such as mercuric 1 :5000, carbolic acid 1 per cent., or tincture of 
iodin 1 per cent. Large volumes of these solutions are needed (quantity not 
strength) to mechanically remove necrosis and such bacteria as lay on the 
surface, besides helping to revitalize such tissues as have not already broken 
down. Sterile water is just as efficient, perhaps more so. Normal saline 
solution should not be used as an irrigation in infected wounds, because par- 
taking to some extent of the characteristics of blood-serum, it forms with 
the semidevitalized tissues a culture-medium for the propagation of bacteria. 
Under no circumstances are strong antiseptics indicated. They produce 
albuminous deposits when in contact with tissue and favor the development 
of necrosis, hence cause the further increase of microorganisms and the 
formation of pus. In contused or lacerated wounds where blood-vessels 
have been destroyed, and consequently the tissues devitalized from lack of 
nutrition, the ragged edges and slough should be carefully dissected away 
without injuring the area whose vascularity is still maintained. Pockets and 
cavities should be sought for, and followed with such irrigations as have 
been described. 



Dry and Moist Dressings 143 

Arrest Further Bacterial Invasion. — This can be accomplished in two 
ways — 

(a) By dry dressings changed daily preceded by warm irrigations. 

(b) By moist dressings changed several times a day. 

Dry Dressings. — Iodoform gauze is generally chosen for this purpose. It 
should be placed loosely in the cavity (if an incised wound) or on the sur- 
face of an infected area (if lacerated or contused), never tightly applied. 
The discharges of the wound coming in contact with the iodoform liberates 
•the iodin. Absorption of the drug takes place not in such quantities as to 
produce further irritation, but sufficient to prohibit bacterial growth. It is 
an antiseptic, not a disinfectant. Sterile dressings are applied over this 
medicated gauze and the part put at rest, which factor will be dwelt on at 
more length later. Until infection is overcome and granulation tissue estab- 
lished these dressings are changed daily, preceded by large volumes of hot 
sterile water or very mild antiseptic solutions to facilitate their removal and 
preclude injury to the developing granulations. Granulation tissue having 
developed, a change of dressings is not needed oftener than every four or 
five days, as in aseptic wounds. 

Moist Dressings. — Plain gauze moistened with hot antiseptic solutions 
(mercuric 1 :5000 or carbolic acid 1 per cent.) are placed on the infected 
area covered with oiled silk which prevents evaporation, and over this are 
laid generous quantities of sterile dressings. These are changed every two 
or three hours. The objection to moist dressings is, that if continued for 
any length of time the tissues become macerated, which certainly favors bac- 
terial growth. As soon as the acute signs of infection have abated and gran- 
ulations developed, dry-gauze dressings should be substituted, which need 
not be changed oftener than every four or five days. As a rule the pus 
which is present prevents the gauze adhering to the wound. It is therefore 
easily removed, but should it be adhered the use of hydrogen dioxid followed 
by copious irrigations is indicated. No traction is permissible. When 
granulation tissue appears it is evidence that bacterial invasion has ceased. 
If the wound originally was of the incised variety attempts should be at once 
made to approximate the edges so as to favor union with as little scar tissue 
as possible. If a contused or lacerated wound sterile dressings are applied, 
over which adhesive straps are placed to prevent excessive gaping of the 
wound and to relieve tension. 

Rest. — This I consider the most essential step in the treatment of any 
wound, and especially so in the infected variety. Nearly any kind of clean 
dressing will have salutary effects providing the part is given perfect local 
rest. On the other hand, the most carefully chosen dressing will have no 
effect toward restoration of the part unless provision is made for rest. I 



144 Hyperemic Treatment 

would much prefer a splint and a bandage without dressings, than plenty of 
dressings and no splint. In all steps that have been given you in the care of 
wounds rest stands as the most prominent factor in the treatment of such 
injuries. It is utilized not only to allow the physiologic conditions that are 
going on to progress undisturbed, but it is employed to obliterate muscular 
action, which is the motor to the lymphatic current and which must be 
reduced in the presence of a local infection to prevent general sepsis taking 
place. 

Biers Hyperemic Treatment. — This as I have told you in one of my early 
lectures is simply an artificial means of procuring for the affected area an 
additional amount of blood, thereby increasing the number of leukocytes 
and causing a greater outpouring of serum, — a method of reinforcement of 
the natural resisting powers of the body. In infected wounds this method is 
employed alone or in conjunction with the treatment I have outlined. 

BIBLIOGRAPHY. 

American Practice of Surgery — Carl R. Darn all, Assistant Surgeon, 
U. S. A. 

Keens Surgery — Geo. W. Crile, M. D. 

Modern Surgery — J. Chalmers DaCosta, M. D. 



LECTURE XV 
FRACTURES 

By the term fracture is understood a broken bone or cartilage. It should 
be borne in mind that the entire bone need not be entirely separated into 
fragments for the injury to be classified under this head. In the so-called 
green-stick fracture some fibers of the osseous structure are undoubtedly 
separated, but the majority are only bent; then under gunshot fractures are 
included perforations of the bone made by the bullet. 

There are as many varieties of fractures as there are authors on this sub- 
ject; it will not be necessary for you as nurses to study the numerous classi- 
fications, so I will only give you a description of the commonest forms. 

Classification. — A simple fracture is one in which there is a break in the 
continuity of the bone with little or no damage to the soft tissue. 

A compound fracture is one where there is a wound through the soft 
tissues producing an atmospheric communication with the point of fracture. 

A simple fracture may become compound. By rough handling at the 
time of injury the broken ends may be forced through the soft tissues, or a 
similar condition can take place by an imperfectly treated fracture in which 
the fragments are not coaptated but meet angularly, causing pressure on the 
soft tissues, and followed by a slough. Compound fractures are exceed- 
ingly dangerous injuries. 

Speaking in the early part of my lectures I referred to some tissues which 
had a high resisting power, while others had a very slight resistance to infec- 
tions ; at that time I mentioned that the marrow of bones had a very low 
resisting index. It is for this reason infection is so liable to occur in com- 
pound fractures, and in their treatment every precaution must be used to 
prevent this complication by employing the acme of surgical antisepsis. 

A comminuted fracture is one where the bone is broken into several 
pieces with a communication between the fragments. 

A multiple fracture is one where the bone is broken in several portions, 
but there is no communication between them. 

An impacted fracture is one in which the broken ends of the bone have 
been driven into each other (dovetailed). 

(145) 



146 Causes of Fractures 

The term green-stick fracture conveys to the intelligence that the bone 
is bent in a manner similar to what you would expect when a force is 
applied to a green stick, — some of the fibers of the bone are broken, but the 
majority are only bent. This fracture is seen chiefly in children. 

A gunshot fracture is a fracture produced by some missile projected by 
an explosive, hence you can easily understand these are all of the compound 
variety and need special care. 

A complicated fracture is one in which severe damage has been wrought 
to the surrounding structures, muscles may be lacerated, nerves and blood- 
vessels injured, or even a dislocation added to a fracture in its vicinity. 

Besides this classification, fractures are also designated according to the 
direction the separation takes between the fragments : An oblique fracture 
indicates that the injury extends obliquely across the bone. A transverse 
fracture separates the fragments at right angles to the shaft of the bone. 
Spiral fractures are those in which the line of separation takes a curved or 
spiral course. Without further comment you can easily grasp the nomencla- 
ture accorded by various authors to this class of injuries. 

Causes of Fractures. — The primary factor in the production of fractures 
is violence, applied either directly to the part or indirectly ; as an example of 
the former may be cited a blow from a club on the forearm fracturing the 
ulna or radius, or one falling on the point of the shoulder and breaking the 
surgical neck of the humerus. The well-known fracture of the clavicle, the 
result of falling on the extended arm, the force being transmitted through 
the member, is an example of indirect force producing fracture. The sec- 
ondary causes of fractures are various. Old age with its degenerative 
processes and the changes that occur in the constituents of the bone whereby 
the osseous structure becomes more brittle, is a predisposing cause. The 
seasons of the year have an influence in this class of injuries. The ice- 
covered streets and sidewalks in winter are certainly likely to cause falls, 
to which may be added the greater tonicity or tension of the muscular system 
during this season. By this you will understand the muscles are held in a 
more rigid condition. Sudden muscular contraction, in bones made fragile 
by disease, will produce fractures without any external violence. This form 
of injury is known as a pathologic fracture. 

Signs of Fractures. — Besides the symptoms of pain, swelling, and possi- 
bly ecchymosis, which are common to other injuries, there are certain other 
signs which are more distinctive in the diagnosis of fractures, although the 
presence of blood occasionally becomes an important diagnostic sign in frac- 



Signs of Fractures 147 

tures of the skull, — as an example, the presence of blood oozing from the 
ear in fractures of the base of the brain (middle fossa). 

(1) Loss of Function. — In most cases of fracture the injured member 
becomes immediately helpless because the bone being broken, the muscles do 
not have stationary points from which to contract. However, in impacted 
fractures where the fragments are driven into each other, and in certain 
gunshot fractures, the muscles still retain their function because the con- 
tinuity of the bone is not entirely destroyed, so that occasionally the injured 
member may be used for a short time. 

(2) Preternatural Mobility. — By this is understood, motion occurring in 
a location where motion should not be present; as an example, if on examin- 
ing the shaft of a long bone mobility is discovered, a conclusion would at 
once be formed that a separation of its continuity had occurred because of 
the abnormal location for motion. When preternatural mobility is noted it is 
prima facie evidence of a fracture. However, this sign is wanting in many 
cases, — as in green-stick, impacted, and some cases of gunshot fractures. 

(3) Crepitus. — By this term is meant a grating of the two fragments 
when brought in contact with each other. This sign is indisputable evidence 
of a fracture. Like the former symptom it is not always possible to obtain 
it, as in fractures at the base of the skull, in impacted fractures, and where 
muscular and other soft tissues are interposed between the broken ends, this 
valuable sign is wanting. In certain diseased conditions of joints a crepitus 
is heard and felt, but to the experienced this form of crepitus (false 
crepitus) is vastly different to the true crepitus of a fracture. The two 
forms of crepitus must always be remembered. 

(4) Deformity. — This is a symptom of other injuries besides those 
referred to. Taken, however, in connection with the signs already men- 
tioned, it becomes an important item. You must not think by the term 
deformity is necessarily understood some angularity in the shaft or some 
plainly visible abnormality in the shape of a bone ; these are present at times, 
but a deformity may exist so slight that it becomes necessary to carefully 
measure the injured member and compare such measurements with the 
opposite side. As an example, in fracture of the head of the femur, it is 
always necessary to measure the distance from the anterior superior spine of 
the ilium to the tip of the internal malleolus of both limbs to ascertain 
whether the injured limb is shorter than its fellow. If such is the case there 
is deformity, but yet so slight as not to be discernible to the unaided eye. 

(5) Radiograph. — In spite of all care it is occasionally impossible to 
obtain the usual signs of fracture when this injury is present. In such cases 
the X-ray in the hands of an experienced radiographer should be relied on. 



148 Repair of Fractures 

This is especially true of fractures of the pelvis, base of the skull, and in 
some cases of impacted fracture, where the most experienced will occasion- 
ally be in error without its use. 

Repair of Fractures. — I shall not attempt to describe in detail the several 
changes which take place in the uniting of bony fragments, but shall only 
give the most important steps in the healing process of these injuries. 

Covering the external surface of bones is a thick fibrous tissue called the 
periosteum, the function of which is to afford nutrition to the bony structure 
it clothes. If the bone is denuded of this covering necrosis, or death of the 
bone, frequently follows, because the blood-vessels which permeate the 
periosteum and finally enter the bone substance for its nutrition, are 
destroyed. On the inner surface of bones, or in other words, surrounding 
the marrow cavity, is a delicate fibrous membrane called the endosteum 
which is richly supplied with blood-vessels. It is chiefly through the -medium 
of these two tissues that the repair of fractures is accomplished, possibly 
aided by certain elements from the surrounding soft tissues. When a bone 
is broken the periosteum, endosteum, and more or less of the neighboring 
structures are torn or lacerated. The consequence is that a certain amount 
of blood escapes around the fracture, forming a clot. This is simply a 
mechanical loss of blood and in nowise (as far as known) aids in the process 
of repair, but is immediately removed by the action of the leukocytes. This 
debris being cleared away, the active steps in new bone formation begin. 
Cells derived from the torn periosteum covering the external surface of the 
fragments begin to proliferate or multiply. The injured endosteum from the 
inner surface of the bone likewise proliferates its cells. In the meanwhile 
small blood-vessels are formed which permeate this newly developed tissue 
and afford it nutrition. The connective-tissue cells from the soft parts which 
were injured around the fracture also begin to multiply. Thus three dif- 
ferent cells are developing around the fractured bone for its repair : exter- 
nally, those derived from the periosteum and the connective-tissue cells from 
the soft parts ; within the bone, those developed from the proliferating cells 
from the endosteum — all of which are nourished by newly developed blood- 
vessels. Thus you will appreciate that Nature is repairing the injured bone 
from within and without. This newly formed tissue is termed temporary 
callus — temporary because the greater portion of it will be absorbed. These 
new deposits are also known as external or enshcathing callus and central or 
medullary callus, according to the location where they are formed ; the terms 
are sufficiently descriptive to need no further explanation. The next step 
in the maturing of this callus (for it is yet in a soft formation) is the deposit 
of lime salts between the cells, which sooner or later partake of the charac- 



Complications of Fractures 149 

teristics of cartilage, and eventually this is transformed into bone. Or cells 
having bony characteristics may develop from the first. The former how- 
ever is the general rule. The process of complete bone formation requires 
from five to seven weeks. These little deposits of cartilage or bone extend 
from one end of the broken fragment to the other. Externally around the 
bone a ferrule-like callus (ensheathing callus) is formed; while within there 
is developed a reinforcement or plug (central callus). The ensheathing 
callus, while it is more or less a deformity at first because of the super- 
abundance of new material thrown out, is eventually absorbed to a greater 
or less extent. If the bones are nicely coaptated only that portion of the 
callus which cements the broken ends remains. This is then termed perma- 
nent callus. If a large gap of bone has to be filled in, or if the fragments 
are not nicely adjusted, Nature does not absorb the superabundance of callus 
and deformity always exists. The medullary or central callus is at times 
absorbed. Thus an analysis of bone repair will demonstrate that the parent 
bone takes no part in the process of its own repair. 

Complications Following Fractures. — The complications which may fol- 
low these injuries are numerous, yet in proportion to the number of frac- 
tures I do not think they are seen as frequently as one might expect. 

Injuries of the Blood-vessels. — These are caused by the sharp ends of the 
fragments cutting one or more of their coats, either at the time of injury or 
through careless handling of the injured member by those giving first aid, or 
during manipulations necessary for the adjustment of the fracture, and 
finally this same complication may arise from improperly adjusted frag- 
ments where great deformity exists. You can easily understand if the main 
artery supplying a limb is irreparably lacerated the circulation may be 
entirely cut off, or the nutrition seriously interfered with. In either case a 
severe hemorrhage will occur. It is self-evident that even though the blood- 
vessels are not lacerated a great deformity existing in the vicinity of large 
blood-vessels can exercise such pressure as to interfere with the circulation. 
Occasionally an injury to the vessel is so great as to necessitate an amputa- 
tion of a limb either immediately after the fracture or subsequently. The 
circulation, too, can be impaired and in fact entirely obliterated by 
improperly applied splints and poor bandaging. Severe swelling occurring 
after a fracture deserves careful consideration. It may be due to concealed 
hemorrhage or an obstructed venous circulation. For the first fezv days 
after a fracture of an extremity the nurse should pay special attention to the 
circulation of the part, the digits (fingers or toes) serving as an index. 

Injuries of the Nerves. — What is true of blood-vessels is also true of the 
nerves supplying a fractured member. They are equally liable to be torn, and 



150 Decubitus 

suffer from displaced fragments or deformity caused by faulty adjustment, 
with the result that certain areas or entire members may be paralyzed. 

Delayed Union — Nonunion — Vicious Union. — When through lack of 
proper treatment the bones are not immobilized ; or when the soft tissues are 
thrust between the fragments at the time of injury; or when the nutrient 
vessels of the bone are destroyed; or when the proper adjustment of the 
fragments has not been made; or when the injured one is suffering from 
impoverished health, as degenerative changes in the blood-vessels, syphilis, 
etc. — delayed union, or even nonunion, is the consequence. After union has 
taken place between the broken fragments of bone and there remains great 
deformity and impaired function of the member, it is termed vicious union. 
These abnormalities, whether or not they be due to a lack of care on the 
part of the surgeon, and frequently they are not, are considered by the laity 
a sufficient justification for malpractice suits. 

The Skin and Superficial Tissues — Decubitus (Bed-sore). — In certain 
fractures, such as those occurring about the pelvis, around the hip- joint and 
vertebral column, in fact in any diseased condition where it becomes neces- 
sary for the patient to be kept in one position for any length of time, the 
pressure exercised by the weight of the body interferes with the blood supply 
to the underlying part to the extent that a slough occurs, leaving an ulcer, 
which is known as decubitus or bed-sore. This is most frequently seen in 
the aged, or those suffering from degenerative changes and whose circula- 
tion at best is impaired. The involuntary escape of urine, the wetting of the 
bedclothing, the lack of a proper toilet after defecation, the escape of the 
contents of sand bags when employed, and bread crumbs and other 
extraneous matter in the bed frequently produce sufficient irritation to be 
the starting-point of such an ulcer. This complication may develop in spite 
of all the cleanliness which may be exercised, and all the care which can be 
bestowed on the patient. Bed-sores may be the cause of death. The patient 
instead of succumbing to the original disease dies from a general infection 
superinduced by this complication. This is mentioned advisedly with the 
hopes of impressing on you the care which should be exercised to prevent 
the formation of these ulcers and the aseptic treatment necessary after their 
development. While the most common location for bed-sores is on the 
superficial tissues over the sacrum and trochanters of the femur, you must 
not think that these are the only localities for their formation. They are 
commonly seen on the heel, back of the head, and elbow, in fact wherever 
a bony prominence is undergoing pressure from the weight of the body. 

Treatment of Decubitus. — Remove body-pressure by the use of an inflated 
rubber ring, give careful attention to thorough cleanliness ; bathe and mas- 
sage the part under pressure several times daily with alcohol or possibly a 



First-aid Treatment 151 

solution of alcohol and alum, or the glycerol of tannin, in an endeavor to 
harden or toughen the tissues. 

After the ulcer has formed, stimulating dressings are indicated, such as 
the balsam of Peru; or the daily or every-other-day application of nitrate 
of silver, the surgeon of course dictating the treatment as he sees fit. Your 
duty will be to prevent if possible the development of such ulcers, and if in 
spite of all care they form, to endeavor to prevent infection by the most 
careful asepsis. 

Infection. — This occurs chiefly in the compound variety of fractures and 
becomes a very grave complication. The septic material may have gained 
entrance at the time of the injury or infection may have occurred later 
through careless methods of dressing the injury. I can think of no accident 
which requires more thorough asepsis than the treatment of compound 
fractures. 

Shock. — This is seen chiefly in severe fractures of the cranium, thorax, 
vertebrae, and pelvis. 

Pneumonia. — This complication may be the direct result of the injury, as 
in fractures of the ribs (traumatic pneumonia) , or it may supervene later, 
especially in debilitated or old subjects who from the nature of their injuries 
are forced to remain in a recumbent position. In these cases the enfeebled 
circulation gravitates to the posterior portion of the lung and produces what 
is known as hypostatic pneumonia. 

The well-trained surgical nurse should be acquainted with these complica- 
tions, not that she will be called on to treat them, but that she will be in a 
position to recognize them the instant they occur, and call the attending sur- 
geon's notice to the same. She should be educated along these lines so that 
the daily memoranda will carefully detail such abnormalities in the course 
of the treatment as will be of interest to the surgeon, and a benefit to her 
patient. 

The Principles of Treatment of Fractures. — First Aid. — From what you 
have learned concerning fractures you will readily appreciate that the treat- 
ment of these injuries begins immediately the accident is received. The 
bystander who renders first aid either performs good service or adds further 
injury by the rough handling of the broken member. Unnecessary manipu- 
lations at this time are wrong. If the patient is to be moved to his or her 
residence or hospital, some temporary means should be employed to 
immobilize the broken bone so as to prevent the sharp fragments from 
lacerating blood-vessels, nerves, and other soft tissues. It is generally good 
policy to remove all clothing from around the injury, this should be accom- 
plished by carefully cutting away the garment so as not to jar or cause 
further pain or injury, as would ensue if attempts were made to remove the 



152 First-aid Treatment 

clothing otherwise. This being accomplished a better opportunity is afforded 
to judge the extent of the injury, to ascertain if hemorrhage is present and 
endeavor to check it, to note whether the fragments are about to transfix 
the soft tissues and produce a compound from a simple fracture; or, if such 
a complication has occurred, it facilitates the application of some antiseptic 
solution if any be at hand. In any case further mangling of the soft parts 
can be prevented by having the clothing removed. First-aid treatment is 
simply a matter of individual ingenuity; the attendant who can improvise, 
is the man or the woman of the hour: no set rules can be given — simply 
suggestions made. 

Fractures of the Lower Extremities. — Immobilize the member by binding 
the same to a light board, or other substitute, at hand — anything of sufficient 
length to brace the fractured member. Under no circumstance should the 
patient attempt to walk. Should the accident have occurred in a locality 
removed from ambulance service, improvise a litter from a wide board or 
even a door. 

Fractures of the Upper Extremities and Trunk — The Arm. — Bind the 
member to the trunk, place the forearm in a sling. 

Forearm and Hand. — Utilize a strip of wood, such as a shingle, portion of 
a cigar-box, or even heavy card board, bind the member to the same and 
suspend in a sling. 

The Ribs.— Nothing can be done in this region to afford much relief, 
because a bandage sufficiently tight around the thorax to abolish muscular 
movement on the injured side will interfere with respiration — nevertheless 
it is the most appropriate treatment. 

Fracture of the Clavicle. — Support the fractured bone by utilizing a sling; 
adjust the same so that the shoulder on the injured side is higher than its 
fellow ; bind the arm to the trunk. 

The Lozvcr Jazv. — Use the upper jaw as the immobilizing agent; hold in 
place with a bandage made from a handkerchief carried from under the jaw 
over the head and tied. 

Fracture of the Vertebrae. — Place on a litter, remove to residence or hos- 
pital ; avoid all unnecessary handling of the patient. 

The Pelvis. — If the symptoms suggest a fracture of this region, encircle 
the bones with an improvised girdle snugly applied. 

Preparation of the Patient. — A fracture being an emergency, preparatory 
treatment is limited. The nurse's duties will vary according to the destina- 
tion of the patient; if it is the hospital, the emergency operating-room will 
be the scene for the final treatment of the injury; if taken home, prepara- 



Dressings for Fractures 153 

tions will have to be made for the patient's reception. But in any case, the 
following steps must be carried out : 

(1) Remove clothing and adjust nightgown. 

(2) Conserve the patient's resisting power by the proper adjustment of 
covers. (There is more or less shock with every fracture.) 

(3) Carefully remove first-aid dressings. 

If a simple fracture thoroughly cleanse and shave the part; dry 
thoroughly. 

If a compound fracture the greatest antiseptic care must be taken. The 
wound is supposed to be infected, therefore large volumes of mild, warm 
antiseptic solutions should be employed to cleanse the wound and the sur- 
rounding area, not in a haphazard way, but in the following manner : 

(a) A protective gauze pad moistened in an antiseptic solution should 

be laid over the wound to prevent any further infection during 
the necessary ablution of the injured member. 

(b) Cleanse the area in the proximity of the injury according to the 

rules given for the "Preparation of Patient for Operation." 

(c) Remove protective pad. 

(d) Thoroughly irrigate the wound with large volumes of mild, warm 

antiseptic solutions. 

Anesthesia. — An anesthetic is used in highly nervous individuals, where 
the patient is suffering severe pain or in cases where muscular contraction 
interferes with the necessary manipulation; and in compound fractures, 
where it has been decided to wire the ends of the bone, or in such cases 
where operative interference other than the adjustment of the fragments 
is necessary. In such cases it may be prudent to lavage the stomach previous 
to the administration of the anesthetic, especially if ether or chloroform is 
to be used. This procedure prevents the unsightly vomiting of the patient, 
shortens the time of the anesthetic, and lessens the danger of the drug. It is 
best accomplished by having the patient drink large volumes of water before 
the tube is inserted. 

Dressings Employed in Fractures. — The objects to be accomplished in 
dressing a fracture are the following : 

(1) To adjust the fragments in as near a normal position as possible. 
This is known as the reduction of a fracture. 

(2) To keep the same in position by perfect immobilization. This is 
accomplished by means of splints, which are simply braces used to retain the 
fragments of bone. They are made from various materials, such as light 
metal, wood, papier-mache, plaster of Paris, and silicate of soda. There 
are numerous kinds of splints sold on the market supposed to be adapted for 



154 Reduction of Fractures 

the various fractures ; but the more you come in contact with practical sur- 
geons, the more you will observe that these ready-made splints are not 
frequently used, the surgeon improvising for the individual case. A good 
splint should be light and possess fair tensile strength, — wood of a proper 
thickness has these qualifications. Several varieties of this material are 
found on the market cut in various lengths and widths, such as bass and 
yucca wood. A splint to be of any practical purpose should be of sufficient 
length to form a stable brace, and wide enough to prevent the constriction 
of the member when the bandage is applied ; in other words, a trifle wider 
than the injured member. To prevent undue pressure it should be thor- 
oughly padded with cotton held in place by a roller bandage. On account 
of its elasticity, the common cotton wadding found on the market is prefer- 
able to the absorbent material for this purpose. In every hospital there 
should be a special room assigned in which are kept the various dressings 
necessary for the treatment of fractures. A fracture is an emergency which 
requires immediate attention. It does not add to the dignity of any 
institution to force the interns and nurses to search every floor for such 
articles as are needed, yet this is not an uncommon occurrence. After a 
fracture appliance has been removed from a patient it should be immediately 
returned to the room designed for such accessories, which should be as nicely 
appointed and kept as any other apartment, — but how seldom is this seen. 

Articles to be Kept in Stock. — 

(1) Bass or yucca wood. Poplar boards of various widths and lengths, 
one-eighth to one-fourth inch in thickness. 

(2) Wire netting, one- fourth-inch mesh. 

(3) Plaster-of -Paris bandages of various widths. 

(4) Strips of sheet metal three-fourths inch wide for reinforcement of 
plaster casts when necessary. 

(5) Rolls of ordinary cotton wadding. 

(6) Gauze roller bandages, various widths. 

(7) Adhesive plaster. 

(8) Extension apparatus. 

(9) Sand bags of different lengths, five to six inches in diameter. 

With these materials the practical surgeon will be enabled to treat the 
majority of fractures. 

Reduction of Fractures. — I have endeavored to outline the preparation of 
the patient before the surgeon attempts reduction. I have tried to give you 
an adequate idea of the materials used in the dressing of fractures. The 
reduction of the fragments is of course the duty of the surgeon. If the 
fracture be of the simple variety the dressings I have mentioned will be 



Common Modifications 



155 



sufficient for the surgeon's needs. If, however, the fracture be compound, 
besides the necessary retaining splints, such surgical materials and instru- 
ments will be required as in other operations, and preparations should be 
made accordingly. 

Some of the More Common Modifications Used in the Treatment of 
Fractures — Change of Splints. — 



^m\\mmm^^W{m^ 





Illustration XXXVIII 

A Plaster-of-Paris Cast. — Showing- a fenester or window cut in the 
same, through which the wound may be dressed without removing 
the immobilizing splint. 



(1) Frequently after the acute symptoms have subsided the ordinary 
wooden or metallic splint is removed and a plaster-of -Paris cast substituted, 
the object being to afford the patient more security from injury, as well as 
to obviate the necessity of having to readjust the bandages. When the 
fracture is of the compound variety, after the plaster-of-Paris cast has been 
molded to the part, a window (fenester) is cut around the point of 
fracture so that dressings may be applied to the wound and still have the 
member immobilized. (See lecture on "Preparation and Sterilization of 
Gowns, Sponges, Dressings," etc., section "Plaster-of-Paris Bandages"; 
Also illustration XXXVIII.) 

Extension. — 

(2) In fractures of the lower extremity, especially of the femur, where 
contraction of the muscles occurs, producing deformity which cannot be 
overcome by the ordinary splints, the surgeon resorts to extension. 



156 



Extension Apparatus 



Buck's Extension Apparatus. — This is made and applied in the following 
manner — 

(a) Shave, cleanse, and thoroughly dry the limb. 

(b) Apply a strip of adhesive plaster three inches wide to both sides of 

the member, beginning a little below the fracture and extending 
the same four to six inches below the sole of the foot, thus form- 
ing a loop. 




Illustration XXXIX 

Buck's Extension Apparatus.— Note the following- points: that the foot of the bed 
is elevated to produce counter extension, that the weight does not touch the floor, 
that the sole of the patient's foot does not come in contact with the footboard, 
that a sand bag is utilized to assist in immobilization and prevent rotation. 



(c) Obtain a piece of wood three inches square and one-fourth inch 

thick; make a hole in the center of this one-fourth inch in diam- 
eter. The wood is then placed on the inner side of the plaster 
loop to which it adheres and reinforces. Cut a hole in the plas- 
ter corresponding to the hole in the wood. 

(d) Protect the prominent bones of the ankle-joint (internal and ex- 

ternal malleoli) by surrounding the same with gauze so as to 
prevent the plaster from irritating. 

(e) Encircle the limb with a well-applied bandage; this makes the plas- 

ter adhere snugly to the member. 



Double-inclined Plane 157 

(f) Pass one end of a cord (sash cord is generally used) through the 

perforation in the plaster loop and its reinforcement of wood; 
knot the same. The other end is carried over a pulley which has 
been attached to the foot of the bed. Apply the necessary weight 
to this end of the cord. 

(g) Elevate the foot of the bed four to six inches, thus obtaining coun- 

ter extension. 




Illustration XL 
An improvised Double-inclined Plane Splint 



(h) Place sand bags on either side of the injured member to afford 
immobilization as well as to prevent eversion of the foot in frac- 
tures of the neck of the femur. (See illustration XXXIX.) 

The nurse should be careful to keep the sole of the foot from coming in 
contact with the footboard and prevent the weight from touching the floor, 
either of which would defeat the purpose of the extension. She should also 
keep the sand bags closely applied to the limb to overcome outward rotation 
and maintain immobilization. 

(3) Double-inclined Plane. — Another common modification for the ordi- 
nary straight splint is the double-inclined plane, the mechanical construction 
of which will be appreciated by referring to the illustration. This apparatus 
is allowed to rest on the bed or may be suspended in a swing. It is used in 
fractures of the shaft of the femur and of the leg. (See illustration XL.) 

(4) Fracture Box. — In fractures of the leg accompanied with great 
swelling, deformity, and damage to the soft tissues, a fracture box is fre- 
quently employed for the first few days until the swelling has subsided, after 



158 



Ambulatory Treatment 



which the permanent dressings are applied. The advantages of this form of 
temporary splint are — 

(a) Inspection can be made of the injured member without disturb- 

ing it. 

(b) Constriction from the use of bandages is obviated. 

(c) Topical applications are easier applied, such as ice, evaporating 

lotions, etc. 




Illustration XLI 

Ordinary Fracture Box. — Observe the profuse loose dressing's within, 
which prevent undue pressure. 



Illustration XLI gives a good idea of its construction. The bottom and 
sides of the box should be generously padded with cotton wadding, and 
pressure removed from the heel of the foot by making a small ring of cotton 
wadding, wrapped with a bandage for this portion of the member to rest in, 
the so called "bird's nest!' 

(5) Ambulatory Treatment of Fractures. — This manner of treating frac- 
tures of the lower extremity is especially adapted to the aged or enfeebled 
patient, whose health will be further reduced if forced to remain in bed for 
any length of time. These are the subjects prone to develop hypostatic 
pneumonia, bed-sores, etc., to obviate which some form of fixation apparatus 
is designed for the individual case, which permits the patient to move about 
after the acute symptoms have subsided. Some surgeons advocate this plan 
of treatment in a wider range of cases than the limitation that is here given. 

Fracture Bed. — In fractures of the vertebrae, pelvis, or lower extremi- 
ties is is necessary that the patient be placed on a firm bed free from any 
sagging which would tend to produce deformity and prevent perfect immo- 
bilization. In such cases a fracture bed is constructed, which consists of 



Fracture Bed Cradle 



159 



boards placed between the mattress and springs. The mattress should be 
of good quality, not soft, and preferably made of hair or felt. 

Cradle. — In injuries of the lower extremities it is desirable that the 
pressure of the bedclothing be kept from the injured member. This is 





Illustration XLII 

Cradle. — The lower illustration is the form used 
in hospitals, while the upper picture gives an 
adequate idea of an extemporized cradle for use 
in private practice. 



obviated by using what is known as a cradle, numerous varieties of which 
are found on the market ; they are made of light steel. An extemporaneous 
apparatus may be made from barrel-hoops placed crosswise and tied in the 
center, as seen in illustration XLII. 

The After-treatment and Care of Fractures. — In fractures of the upper 
extremity the patient is usually allowed the freedom of going and coming 



160 After-treatment 

as he pleases after the fracture has been reduced. This is the ideal in all 
fractures wherever occurring, because the sudden transition from an active 
life to one of inactivity leaves its impression more or less on the patient. The 
general health suffers, and especially is this true of the aged who cannot 
tolerate confinement. The organs of excretion become sluggish ; the appetite 
depreciates and insomnia is more or less present. 

In fractures of the lower extremities, pelvis, vertebrae, or cranium, it is 
compulsory to confine the patient to bed. In these cases it becomes necessary 
to use every endeavor to prevent such complications as may develop because 
of the recumbent position of the patient, such as bed-sores, hypostatic pneu- 
monia, bronchitis, etc. The patient therefore should be allowed to sit up as 
soon as possible. Alcohol baths and massage should be administered, spe- 
cial attention being given to such portions of the body as are under pressure. 
The Bradford frame is useful for cases of this kind. It consists of a rec- 
tangular frame constructed of steel tubing over which is stretched two pieces 
of stout canvas, leaving an opening at the site of the buttocks. It is raised 
by means of pulleys. By this method the sacrum and other prominent por- 
tions of the pelvis which are liable to bed-sores can be massaged daily, and a 
thorough toilet made after each defecation. The danger also of displacing 
the fragments when moving the patient to use the bedpan is reduced to a 
minimum. 

In fractures of the pelvis or of the head of the femur it frequently will 
be necessary to resort to catheterization because of the inability of the 
patient to urinate. In these cases a careful watch should be made for the 
presence of blood which is suggestive of an injured bladder. 

If blood is discovered in the feces a notation should be made on the chart, 
and the surgeon's attention called to it. // the thorax has been the seat of 
accident bloody expectoration is indicative of an injury to the lung. 

In all cases of fractures of the extremities special attention should be paid 
to the fingers or toes for the first three or four days to ascertain the con- 
dition of the circulation. Edema or swelling of these parts may indicate an 
obstructed circulation — an obstruction due to laceration of the veins, pres- 
sure from misplaced bones, or poorly applied dressings. 

Diet. — A soft diet is indicated for the first two or three days. 

Passive Motion. — At a variable time, generally two to four weeks, depend- 
ing on the location of the fracture and the individual ideas of the surgeon, 
careful and slight movement is made of the injured member, gradually 
increasing the radius of motion from day to day; the object being to prevent 



After-treatment 161 

any unnecessary loss of function of the member. This is termed passive 
motion. 

Nurse's Duties. — These have been sufficiently explained in the text of the 
lecture to make a summary unnecessary. 

BIBLIOGRAPHY. 
American Practice of Surgery — Duncan Eve, M. D. 
Keen's Surgery — Daniel N. Eisendrath, M. D. 



LECTURE XVI 

DISLOCATIONS AND SPRAINS 

An Articulation or Joint. — When two or more segments of the skeleton, 
whether osseous or cartilaginous, are connected together it is termed a joint 
or articulation. It is not necessary for a wide range, or any motion to be 
present, to come within this definition; as in the articulations between the 
vertebrae only slight movement is present. Again, some joints are immov- 
able, as those in the adult cranium; nevertheless the junction of these bones 
is considered an articulation. As a general proposition I think it may be 
stated that the more highly organized the joint, the greater range of motion 
it possesses, and vice versa. You can easily understand there are other tis- 
sues which enter into the construction of an articulation besides the bony 
structures. Among these may be mentioned cartilage. There are several 
varieties of this tissue, each having certain functions. The cartilaginous 
discs between the vertebrae, not only unite the vertebral bodies, but act more 
or less as shock absorbers. The semicircular plates of cartilage on the head 
of the tibia form concavities for the reception of the convex lower extremity 
of the femur. 

Ligaments. — These serve as binding media to lace or connect the 
articular end of one bone to the other and are composed of fibrous tissue, 
which is strong, tough, flexible, and practically inelastic, permitting of a 
wide range of motion without stretching unless under great strain. 

The Synovial Membrane. — This is a thin serous tissue which extends 
from the circumference of one articular surface to that of the other, 
thus forming a closed sac or cavity. It lines the inner surface of the liga- 
ments which connect the bones together, and clothes any tendon which 
passes through this cavity. This serous tissue does not cover the articular 
ends of the bone. It is supplied with the same blood-vessels and nerves 
which nourish and innervate the joint. Its function is to lubricate the joint, 
to supply "joint water," as it is vulgarly termed. This membrane is very 
susceptible to infection, and easily becomes inflamed when injured. 

Tendons. — These do not enter into the formation of a joint and are only 
mentioned in connection with an articulation, because they are the motors 

(162) 



Classification of Dislocations 163 

which functionate the joint. The tendon of a muscle is the distal portion 
which eventually is attached to the osseous structure. Frequently in inflam- 
mation of a joint, the tendon also becomes inflamed. 

Dislocations are persistent displacements of two articular surfaces. A 
sprain is a temporary separation. In other words when a joint is dislocated 
the articular ends are so displaced that they cannot readjust themselves and 
persist until artificial aid is afforded ; while in sprains the disarrangement of 
the articular surfaces readjust themselves without assistance, — hence only 
a temporary separation. 

Classification of Dislocations. — The classification of these injuries fol- 
lows to some extent that of fractures. 

(1) A complete dislocation is one in which the articular surfaces are 
entirely separated from each other. 

(2) An incomplete dislocation (also termed partial dislocation or sublux- 
ation) is where the articular ends of the bones are not completely separated. 

(3) A compound dislocation is one where there is an atmospheric com- 
munication with the joint, — there is a wound through the soft tissues. 

(4) A simple dislocation, as the name implies, is where there is a separa- 
tion of the articular surfaces with little damage to the surrounding parts. 

(5) A complicated dislocation is the reverse of the last described variety. 
Injuries have occurred to the soft tissues; vessels or nerves may be torn, or 
one of the bones forming the joint may be fractured. 

(6) A congenital dislocation is one that occurs in utero, and does not in- 
clude those which happen during childbirth. 

(7) An old or ancient dislocation is one of long standing, in which inflam- 
matory changes have taken place in the soft tissues and the articular sur- 
faces themselves have been more or less obliterated by fibrous deposits. 

Besides these classes some authorities have attempted an anatomical divi- 
sion of these injuries, aiming to describe the dislocation according to the 
new position which one articular end of the bone has assumed. As an ex- 
ample: a subglenoid dislocation is one where the articular head of the hu- 
merus lays below the socket (glenoid cavity). A dislocation of the femur 
on the dorsum of the ilium indicates that the head of the femur is resting 
on the posterior portion of that bone. 

Causes of Dislocations. — Exciting Causes. — 

(1) Violence. — This may be the result of direct or indirect force. As 
an example of the former, a sudden wrench of the ankle dislocating that 
articulation. Indirect force travels through the length of the bone or mem- 



164 Causes of Dislocations 

ber producing a dislocation of some remote joint — as a dislocation of the 
shoulder as the result of a fall on the outstretched hand. 

(2) Muscular Action. — A dislocation of the lower jaw occurring during 
the act of yawning, or the displacement of the head of the humerus in the 
effort of throwing a ball, are examples of injuries caused by muscular 
action. There is every reason to believe that muscular action plays an im- 
portant role in all varieties of dislocations even where violence is the ex- 
citing cause. Again in certain diseased conditions of the joints where the 
articular surfaces are eroded the constant contraction of the muscles causes 
separation of the articular surfaces, producing what is known as a patho- 
logic dislocation. 

Predisposing Causes. — 

(1) Destructive Joint Disease, as has already been mentioned in connec- 
tion with muscular action. 

(2) Age. — This form of injury is more prevalent in middle age. 

(3) Sex. — The male with the usual increased muscular development is 
more predisposed. 

(4) The various occupations which require great muscular effort. 

(5) The anatomical mechanism of the joint bears an important relation 
to dislocations. The greater the range of mobility in an articulation, the 
more predisposed is such a joint to dislocation, hence the ball-and-socket 
joints are the articulations generally involved. 

Signs of Dislocations. — 

(1) Pain is present immediately. Swelling ensues rapidly. Ecchymosis 
is a delayed sign. 

(2) Preternatural Immobility. — The motion of the joint is limited, — 
some actions may still be retained, but the majority are abolished. 

(3) Loss of Contour of the Joint — Deformity. — In comparing the in- 
jured articulation with its fellow of the opposite side a change in form is at 
once seen, possibly the rotundity of the well member gives way to a flat or 
angular condition of the injured one. 

(4) The presence of the articular end of the bone in an abnormal posi- 
tion, or its absence from the normal location. As an example, the finding 
of the head of the humerus in the axilla (arm pit) and the absence of it 
from the glenoid cavity (socket). 

(5) The radiograph. By this means the diagnosis is confirmed. 



Changes in the Joint 165 

Differentiation between Fractures and Dislocations. — 
Fractures. — 
Preternatural mobility. 
Crepitus present. 

Deformity returns after reduction unless artificial means are used to 
maintain the fragments. 

Dislocations. — 
Preternatural immobility. 
Crepitus absent. 

Deformity disappears and remains absent after reduction. 
In complicated dislocations the signs of fracture and dislocation may both 
be present. The radiograph demonstrates the actual condition in any case. 

Changes Occurring in the Joint after Dislocation (Pathology). — 

I shall confine my remarks to changes produced about the joint, the result 
of dislocations of traumatic (violent) origin, and not include those occur- 
ring as a sequence of diseased joints (pathologic dislocations). 

When an articulation has been dislocated as the result of violence, the 
ligaments are torn or lacerated; the synovial membrane ruptured; cartilages 
possibly displaced to a greater or less extent, and the periosteum stripped 
from the bone where articular ends have been fractured. As a rule the 
nerves and blood-vessels do not suffer, although these are occasionally im- 
plicated. When a vessel of any size is damaged, a severe hemorrhage 
occurs around the joint, causing great swelling; while an injury to the nerve 
produces a neuritis which persists for some time after the accident and occa- 
sionally, as in dislocations of the shoulder, a partial paralysis may develop. 

In ancient dislocations the inflammatory action which ensues at the time 
of injury agglutinates the soft parts in abnormal positions. The articular 
surfaces are filled with new deposits. Reduction therefore is impossible 
unless surgical procedures are resorted to. Occasionally in an unreduced 
dislocation the bone forms a socket for itself in a new location and a fairly 
useful joint is the result. 

Ankylosis. — When an inflammatory action occurs in a joint, the result of 
infection or the sequence of violence, the results of such inflammation are 
capable of destroying the mobility of the articulation to a greater or less 
extent by the formation of exudates. This condition is termed ankylosis. 
Constitutional diseases such as rheumatism can also produce such 
deformities. 

Treatment of Dislocations. — First Aid. — A dislocation should be reduced 
immediately, before swelling ensues and muscular contraction complicates 



166 Treatment of Dislocations 

the reduction. The clothing should be cut away from the injured member. 
Under no circumstances should attempts be made to change the position 
which the member assumes, as this is the most comfortable to the patient. 
Unnecessary manipulations may further lacerate the soft tissues around the 
joint; in fact, rough handling of a dislocated member frequently causes as 
much or more injury than the primary accident. Support the member by 
such improvised means as are at hand. Remove to house or hospital. Sum- 
mon the surgeon. In the interval apply cold applications to prevent undue 
swelling. 

If a compound dislocation, the wound should be immediately protected 
in an endeavor to prevent infection entering this portal and producing in- 
flammatory changes in the joint. 

After first aid has been rendered there are three indications to be met — 

(1) Reduction. 

(2) Immobilization. 

(3) Endeavor to prevent inflammation. 

Reduction. — It is the surgeon's province of course to reduce dislocations. 
All necessary manipulations therefore will be made by him. As a general 
proposition it is not only easier for the surgeon, but safer for the patient, to 
have an anesthetic administered. Muscular rigidity is thus overcome, ten- 
sion is relaxed, and the bones are easier manipulated and with less damage 
to the tissues. Dislocations are emergencies ; the preparatory treatment of 
the patient before the administration of the anesthetic under such circum- 
stances, has been suggested in the lecture on "Fractures." 

Immobilization. — Bearing in mind the conditions present in dislocations, 
it will at once become apparent that immobilization is necessary to allow the 
repair of the soft tissues and absorption of any effusion or exudation which 
may develop around the joint. This is accomplished by splints properly 
applied. 

Endeavor to Prevent Inflammation. — After reduction and immobilization 
have been accomplished the application of ice bags prevents swelling and 
effusion to a great extent, besides rendering comfort to the patient. 

If the dislocation be of the compound variety surgical procedures are 
indicated. The necessary instruments and dressings should be provided for 
the surgeon, as in all probability counterincisions will be made to afford free 
drainage. 

Treatment of Sprains. — As I have already stated, sprains are only a tem- 
porary separation of the articular surfaces, spontaneous reduction takes 
place, so that the indications for treatment will be immobilization and an 
endeavor to prevent inflammation by the use of refrigerant applications and 



After-treatment of Dislocations 167 

evaporating lotions. In other words, the treatment of sprains is similar to 
the treatment of dislocations after the latter have been reduced. 

After-treatment of Dislocations and Sprains. — This is practically the 
same as the after-care of fractures. The invalidism of the patient is not as 
prolonged in this class of injuries ; passive motion of the joint is begun 
earlier; the complications which arise in fractures are not apt to occur in 
dislocations excepting in the compound variety. 

Nurse's Duties. — These have been sufficiently explained in the lecture to 
make a summary unnecessary. 

BIBLIOGRAPHY. 
Modern Surgery — J. Chalmers DaCosta. M. D. 



LECTURE XVII 

BURNS AND SCALDS 

These are injuries caused by the action of heat, although the effects of 
caustics and acids, and the results of lightning or electricity, are included 
under this head. This form of injury is classified as first-, second-, and 
third-degree burns, so as to give an intelligent description of each variety. 

First-degree Burns. — These are characterized by a simple redness of the 
skin — erythema. This symptom continues for several days and is fre- 
quently followed by desquamation. Sunburn is a typical example of this 
injury. Simple as the ordinary cases of sunburn appear, you must not con- 
clude that first-degree burns are inconsequential. If a large area of the 
skin-surface is involved, serious symptoms may develop and even fatalities 
ensue if two-thirds of the body-surface is involved. No deformity results 
from this degree of burn. 

Symptoms and Course. — When a small surface is involved slight pain of 
a burning nature is present, and the constitutional symptoms are few if any. 
On the other hand if large areas are affected general disturbances will be 
manifested. The circulation shows signs of distress, the heart's action be- 
comes weak, the extremities cold, and body-temperature drops below nor- 
mal. The nervous system in proportion suffers, pain is intense. Shock 
occasionally develops. The digestive and urinary systems do not escape. 
Vomiting ensues, diarrhea or constipation may be present. The function 
of the kidneys may be reduced, the urine bloody and practically suppressed. 
You must therefore appreciate that in dealing with burns of the first degree 
covering large tracts of cutaneous nerves, efforts should be prompt, looking 
toward the relief of the patient. 

Local Treatment. — Apply some demulcent to the affected part, such as the 
officinal oxid of zinc ointment freshly prepared, or boracic-acid ointment 
(4 per cent.), or carron oil (equal parts of lime water and linseed oil), over 
which place generous dressings of gauze held in position by roller bandages. 
Wet dressings may be substituted consisting of several layers of 20 by 24- 
mesh gauze moistened in normal salt solution or 0.50 per cent, carbolic-acid 

(168) 



Second-degree Burns 169 

solution, or a saturated solution boracic acid, or a solution of aluminum 
acetate, over which is placed rubber tissue and a suitable bandage applied. 

Constitutional Treatment. — The first indication is the relief of pain by a 
suitable dose of morphin administered hypodermatically. If the heart's 
acton is getting faster and weaker, and symptoms of shock are becoming 
manifest, an infusion of normal saline solution with adrenalin is indicated. 
Proctoclysis is applicable in cases of acute nephritis complicating the acci- 
dent. Digestive disturbances are met with appropriate remedies. 

Second-degree Burns. — These are characterized by the formation of 
vesicles or blebs and are generally produced by boiling water or steam. The 
contents of these blebs is a clear serum at first which later may become gel- 
atinous. Sloughing with scar formation does not develop in first- or second- 
degree burns ; if, however, a second-degree burn becomes infected, such a 
condition may be produced. 

Symptoms and Course. — These are practically the same as those of first- 
degree burns, only more intense. In severe forms the excessive stimu- 
lus made on the medullary centers is so great that shock is not uncommon. 
Congestions in the deeper viscera are not infrequent, the cerebrum also is 
occasionally involved. Constipation or diarrhea will be present. Ulcera- 
tions occur in the intestines and produce hemorrhages. Pneumonia may 
develop. Acute nephritis appears, due possibly to the extraction of serum 
during the formation of vesicles and to the disintegrative changes taking 
place in the blood. At times complete suppression of urine is noted. 

Local Treatment. — The primary object in view in the local treatment of 
burns of the second degree is to prevent infection. An accident character- 
ized with the formation of blebs on a surface which is not sterile has all the 
opportunities of becoming infected when the vesicles rupture spontaneously 
or are opened mechanically, by infectious material coming in contact with 
the denuded surface. The highest degree of asepsis, therefore, must be 
maintained. 

The first-aid dressings cannot be accomplished as aseptically as subse- 
quent ones, hence the puncturing of the blebs should not be undertaken at 
that time. Later, however, when the patient is relieved of pain and the 
stage of shock has passed, a methodical dressing of the injury should be 
undertaken. This is accomplished by thoroughly cleansing the surrounding 
area with mild antiseptic solutions of boracic acid (4 per cent.) or carbolic 
acid (0.50 per cent.), after which the blebs should be punctured at their 
most dependent portion; but the covering of the vesicles allowed to remain 
intact. All shreds and denuded tissue should be carefully excised. To 
complete the dressing a boracic-acid ointment or some similar demulcent is 



170 Third-degree Burns 

applied, over which is laid several layers of gauze covered with generous 
amounts of cotton and held in place by suitable bandages, or the moist dress- 
ings as spoken of in first-degree burns may be used and covered with rubber 
tissue. If infection occurs moist dressings are preferable, and the subse- 
quent treatment is the same as suggested for infected wounds. A frequent 
change of dressings is inadvisable except in infected cases. 

The Constitutional Treatment. — This is the same as suggested in burns of 
the first degree. The relief of pain is imperative in an endeavor to prevent 
severe impressions being made on the centers in the medulla. Shock is re- 
lieved by the intravenous infusion of normal salt solution combined with 
adrenalin chlorid and such other steps as have been advised in the lecture on 
this subject. (See lecture on "Surgical Shock.") Acute nephritis, ulcera- 
tion of the intestines, pneumonia, and other complications will be met with 
the appropriate treatment. 

Third-degree Burns. — These are characterised by actual charring or car- 
bonization of the tissues to a greater or less degree. The skin itself may be 
the only tissue involved, or the injury may be extended through all the tis- 
sues. The slough thus caused is termed an eschar. 

Symptoms and Course. — The pain is generally not as severe as burns of 
the second degree, because the nerve endings have been destroyed, neverthe- 
less this will depend to a great extent on the amount of surface involved 
and the part which is injured. The usual symptoms of burns are present, 
the weak heart, the lowered blood-pressure, and the nervous phenomena are 
very common. Congestions of the abdominal viscera associated with ulcer- 
ations especially of the duodenum are frequently seen, while cerebral and 
pulmonary complications are also found in this degree of burns. The 
urinary system suffers, not only because of the direct deleterious effects of 
the heat on the kidneys but because of the disintegrative changes in the 
blood and the extra demands suddenly made on these organs to eliminate 
large quantities of body toxins. Depending on the depth of the burn and 
the amount of sloughing which ensues* deformities of all kinds are the 
result. 

Local Treatment. — Burns of the third degree should be treated similarly 
to infected wounds ; warm, moist, mild, antiseptic dressings should be used 
and changed every three hours. As soon as possible (which will be about 
the sixth or seventh day) the eschar or slough should be carefully dis- 
sected from the healthy tissue, and the moist dressings continued until a 
healthy granulating surface is established, when dry dressings may be sub- 
stituted. These are changed every three or four days, the same care being 
exercised not to damage the granulating surface while removing the adher- 
ent gauze. If the granulations appear pale and anemic, a 10-per cent. 



Death from Burns 171 

balsam-of-Peru ointment may be used. (See lecture on "Wounds.") Skin- 
grafting should be resorted to early with the hope of lessening the deformity 
caused by scar tissue. Frequently operations are imperative to correct the 
many deformities that result from this class of burns. The caution which 
has been given you with regard to thorough asepsis in the care of second- 
degree burns applies with equal, or possibly greater force to this variety. 
The large sloughs of dead tissue which occur are accompanied with an equal 
amount of pus. These sloughs form a fertile culture-medium for the propa- 
gation of bacteria, the absorption of which means infection. In your prepa- 
ration for dressings and personal toilet every step in the chain of asepsis 
must be carried out in detail. 

Constitutional Treatment. — This is the same as has been suggested in 
burns of the second degree. Proctoclysis is especially indicated. 

Causes of Death from Burns. — Fatal results may occur from the fol- 
lowing : 

(1) Shock. 

(2) The disintegration of the elements of the blood, due to the extreme 
heat. 

(3) Embolism. 

(4) The loss of blood-serum. 

(5) Acute nephritis, caused by the excretion of excessive toxic elements 
by the kidneys. 

(6) Secondary hemorrhage. 

(7) General infection. 

(8) Complications of the deeper viscera, such as pneumonia. 

Prognosis. — When one-half of the body-surface is burned a fatality may 
be expected. The extremes of age are especially susceptible to these 
injuries. 

Nurse's Duties. — 

(1) Summon the surgeon. 

(2) If the patient is in great pain administer a proportionate dose of 
morphin hypodermatically. 

(3) Put the patient at rest immediately; remove all clothing and substi- 
tute hospital nightgown. 

(4) Prepare dressings. 

(5) Prepare intravenous infusion of normal salt solution with adrenalin 
chlorid. 



172 Electrical Burns 

The first aid having been rendered the secondary duties of the nurse 
begin. 

( 1 ) Pay careful attention to the pulse and temperature. 

(2) Note the character of the respirations. If inspiration be difficult it 
may be due to an acute inflammation of the glottis which demands imme- 
diate surgical attention. Examine the stools to ascertain if blood is present. 
This complication may develop days after the accident. 

(3) Note the amount of urine. Have specimens sent to the laboratory 
for examination. 

Electrical Burns. — Lightning Stroke. — The local effects on the skin are 
similar to those which have been described as the result of contact with heat. 
Frequently it is impossible to estimate the extent of tissue damaged until 
sloughing occurs: Formerly it was not infrequent to witness X-ray burns 
developing days after the exposure, and the resulting slough still later. The 
chief effects, however, of electrical burns from whatever source are mani- 
fested in the cerebro-spinal system and the deeper viscera of the body, the 
phenomena of which will vary from mere dizziness, headache, and general 
nervousness to the different forms of paralysis and the obliteration of the 
special senses. Rupture of internal organs as the result of lightning stroke 
is not uncommon. Instant death is frequent. 

Local Treatment. — This is the same as has been advised for burns due to 
other causes. 

Constitutional Treatment. — Artificial respiration may have to be employed 
and maintained at least one-half hour, together with cardiac massage. Main- 
tain the body-temperature by the use of artificial heat. (See lecture on 
"Anesthesia — Anesthetics," section "Chloroform Accidents.") 

BIBLIOGRAPHY. 
American Practice of Surgery — Benjamin T. Tilton, M. D. 
General Surgery — Lexer-Bevan. 



LECTURE XVIII 

FREEZING AND FROST-BITES 

The effects of cold on the human economy depend on several factors, viz., 

(1) The severity of the cold. 

(2) The length of exposure. 

(3) The humidity of the atmosphere. 

(4) The velocity of the wind. 

(5) The physical condition of the one exposed — the anemic and poorly 
nourished, the extremes of age and the alcoholic subject, are more sus- 
ceptible to low degrees of temperature than those in the opposite physical 
state. 

Classification. — 

Freezing may be divided into local and general. 

Local Freezing. — I shall consider three degrees of this condition. 

First Degree. — This is characterized by a short interval of hyperemia. 
The blood-vessels are dilated and the skin becomes red, followed sooner or 
later by a contraction of the superficial blood-vessels with its accompanying 
anemia (lack of blood). Pain is more or less present at first. Gradually 
this latter symptom subsides, due to the anesthetizing effects of the cold on 
the nerve endings supplying the part. The one exposed is oblivious to the 
actual condition which is developing until some one calls attention to it, or 
upon entering a warm room the frozen part becomes swollen and painful. 
The contracted blood-vessels again dilate and sensation returns, the result 
of the thawing of the nerve endings. Anesthesia, however, may remain for 
several days. The results of this degree of frost-bite are either perfect res- 
toration of the part to normal, or more or less permanent dilatation of the 
blood-vessels, producing unseemly blushes. 

Treatment. — The popular method of rubbing the affected part with snow 
or other cold medium is proper, the idea being to gradually increase the tem- 
perature. Under no consideration should warmth be suddenly applied as in 
this way permanent changes in the blood-vessels may occur. 

Second Degree. — This is manifested by the formation of blebs or vesi- 
cles. When conditions permit the development of the effects of cold on 

(173) 



174 Local Freezing 

the economy, the arteries remain contracted for a greater period than in 
frost-bites of the first degree. The outflow of blood from the capillaries to 
the veins is so reduced as to be inadequate to preserve a free return current 
toward the heart. Blood-stasis (slowing of the blood-current) therefore 
occurs in the smaller veins, transudation of the blood-serum ensues, result- 
ing in the formation of vesicles. The local symptoms are the same as in 
frost-bites of lesser degree, with the addition of vesicles. The results of 
this accident are restoration to normal, unless an infection takes place when 
the blebs are ruptured. In such cases ulcers may develop, which at times 
are exceedingly difficult to heal, because of the dilatation of the vessels. 

Treatment. — The primary principles of treatment are the same as in frost- 
bites of the first degree. After the appearance of blebs, the treatment will 
be similar to burns of the second degree with the usual precaution to prevent 
infection when the vesicles rupture spontaneously or are punctured. 

Third Degree. — This is simply a condition in which the blood-vessels 
have so contracted that the circulation ceases in the part ; or on account of 
the prolonged exposure, the blood itself has become frozen and the vessels 
filled with thrombi (blood clots). The circulation is thus obliterated, the 
part receives no nutrition, gangrene or death of the tissues is the result. 

The process of repair will necessarily be granulation tissue (second in- 
tention) with its accompanying cicatrix. An entire member may be lost; 
or infection following the gangrenous process so severe as to produce a 
fatality. 

The difference between burns and local freezing of the third degree is, 
that in the former one knows the extent of local injury at once, whereas in 
this class of freezing some days may elapse before it is possible to tell the 
amount of damage the patient received. In other words, it is impossible to 
foretell whether treatment will dilate the contracted blood-vessels and re- 
store the circulation to the part. 

Treatment. — When fears are entertained that the circulation is seriously 
damaged, Von Bergman's method should be utilized which consists in sus- 
pending and immobilizing the member vertically so as to favor venous return 
of blood. Gangrenous areas forming in spite of these efforts, warm, moist, 
mild antiseptic dressings are used locally. Amputation of a member will 
not be undertaken until the line of demarkation has formed, separating the 
dead from the living tissue. 

Chilblains are simply repeated frost-bites which have damaged the local 
circulation and caused a proliferation (or increase) of the superficial and 
deep tissues. They appear chiefly on the toes, producing the discomforts of 
itching and pain when the feet become cold in winter. Treatment is unsat- 



General Freezing 175 

isfactory; tight shoes and clothing which constrict the part should be 
prohibited. 

General Freezing. — The same conditions are present in general freezing 
as have been noted in local frost-bites, the only difference being the entire 
body is suffering from the effects of the cold, and the degree of penetration 
is greater. The superficial circulation is interfered with due to the con- 
tracted capillaries supplying the skin. The deeper blood-vessels sooner or 
later undergo a similar change, their caliber is contracted, consequently the 
nutrition and body-temperature are lowered until eventually the entire cir- 
culation is so impoverished that no barrier is left to offset the effects of the 
cold on the deep tissues. The heart's action becomes slower, and the vital 
centers of the cerebrum soon manifest their inability to functionate because 
of the lack of blood-supply. Respiration becomes more shallow and drowsi- 
ness soon develops. If the patient can find shelter or assistance this con- 
dition will possibly be overcome. If on the other hand, aid is not forth- 
coming, the intolerable sleepiness overcomes the sufferer and death ensues. 
Every fluid and tissue of the economy is frozen. One of the most impres- 
sive cases that has ever been brought to my attention was the following : A 
patient of mine moved from this city to one of the Western states and be- 
came a mail carrier for the government, making trips daily remote from 
habitation. Failing to make his appearance for a day or two, fears were 
entertained as to his safety. Searching parties were sent out and eventually 
found him standing in an erect position with one limb raised as in the act of 
taking a step, but completely congealed in a frozen mass, held in position by 
bushes and snowdrifts. 

The question may arise as to how low the body-temperature can be re- 
duced and still hopes entertained of recovery. Pilcher, in the American 
Practice of Surgery, says that cases of recovery have been reported in which 
the temperature was reduced to 76°, 80°, and 81 °F., while Lexer-Bevan 
state that there is a possibility of resuscitation when the rectal temperature 
is not below 68° F. 

The results of general freezing may be restoration to normal ; or, when 
convalescence is apparently established, a fatality may suddenly ensue either 
from a pneumonia, nephritis, or possibly a general infection induced by the 
absorption of the disintegrative changes that have taken place in the tissues. 
You can easily understand that in cases of general freezing all forms of local 
freezing may be seen in different parts of the body, — that is to say, a second- 
degree frost-bite may be observed on one of the extremities, while an ear 
or the nose that was not in any way protected may be in a state of gangrene. 

Treatment. — This should aim to prevent any rapid or sudden thawing of 
the tissues which would cause too rapid absorption of the large products of 



176 Nurse's Duties 

blood-disintegration. The patient should be removed to a cold room and 
rubbed with snow, cold water, or given cold baths, the temperature being 
gradually increased. If respiration is impeded, artificial means should be 
employed to encourage this function. Atropin may be given hypodermatic- 
ally, together with heart stimulants. The condition of the patient will be the 
best indication as to how long cold friction should be maintained. The tem- 
perature of the baths may be gradually increased until, possibly after three 
or four hours, the patient is brought to a temperature of 85° or 90° F. 
Warm stimulating drinks may then be administered and pain, which is 
usually intolerable when thawing begins, controlled by morphin. 

Nurse's Duties. — These have practically been brought before your mind in 
my endeavor to impress on you the principles on which the treatment of 
freezing is based, — to prevent too rapid thawing, either in local frost-bites or 
in general freezing. In this latter condition, however, a relay of nurses will 
be necessary to carry out the hours of constant work which will be required 
before the patient is out of danger. The other details which will devolve on 
you can easily be gathered from your knowledge of the condition, remem- 
bering that even though the patient's temperature and pulse have returned 
to normal, pneumonia may develop, or a nephritis insidiously ensue, or gen- 
eral infection overwhelm the patient. 

Your duties therefore will be to accurately chart the excursions of pulse 
and temperature and note the number of respirations. The amount of urine 
should be daily calculated, and specimens of this excretion sent to the labora- 
tory for examination. 

BIBLIOGRAPHY. 
American Practice of Surgery — P. M. Pilcher, M. D. 
General Surgery — Lexer-Bevan. 



LECTURE XIX 

THE OPERATING-ROOM AND ITS EQUIPMENT 

This room should be spacious and light — facing the North preferably — 
constructed with a large bay window and generous skylight; the floors 
should be of pure white tile, and the walls smoothly finished with cement 
plaster and white enamel. There should be no sharp angles or corners, and 
all unnecessary woodwork should be dispensed with. The corners of en- 
trances should be rounded, and they should be without doors. The swinging 
of a door disturbs the atoms of atmosphere, besides which they are useless. 
The floor-plan of such an operating-room and its auxiliary rooms is clearly 
shown in illustration XLIII. 

Heating. — This should be accomplished by hot water or steam, so arranged 
that the temperature is always kept at 70°F., but which can be instantly 
raised to 80° F. when the room is needed. In calculating the radiation of an 
operating-room 100 per cent, more should be installed than is ordinarily 
necessary, as the large amount of glass entering into its construction lowers 
the temperature rapidly. The fact that at any moment this apartment may 
be pressed into service necessitates facilities for quick heating. 

Artificial Illumination. — This should be perfect and consist of a cluster of 
modern high-power Tungsten lights incased in a frosted globe suspended 
over the operating-table. The lights thus protected give a softer illumina- 
tion and are easier kept clean. Tungsten frosted bulbs should also be in- 
stalled in the ceiling. Electric sockets should be placed in convenient loca- 
tions to the operating-table; to these are attached (when necessity demands) 
extension cords for a portable hand reflector, or the drill for bone work, or 
the cautery. Dirty electric cords dangling over the operating-table should 
never be used for such purposes. All electric currents should be manipu- 
lated by wall switches. 

Water. — There should be an ample supply of sterile water, both hot and 
cold, with the faucets (controlled by foot levers) placed above a white por- 
celain (vitreous china) sink fitted with sanitary trap. The location of the 
water equipment should be in proximity to the nurse in care of the sponges ; 

(177) 



178 



Furniture Equipment 



this will obviate the necessity of her leaving her post of duty, which gener- 
ally happens at the wrong moment. 

Furniture. — The ideal operating-room should have only such furniture as 
is needed for practical use, and it should be of the modern aseptic type 
throughout. 

(1) The Operating -table. — This should be so constructed as to enable the 
anesthetist to control the different positions without moving from his place 
at the patient's head, and disturbing the surgeon. It should be easily 
adjusted to the Trendelenberg, the reverse Trendelenberg or Hartley posi- 
tion (which latter is used for operations on the head and neck) ; it should 
also be so designed as to allow easy access for operations on" the rectum and 
vagina, besides having the proper elevators for gall-bladder, kidney, and 




CORRJJDOR 



CORRJX>OFL 



1 gZ&JfcfJ l % ir r 



Illustration XLIII 

The Floor-plan of the Operating-room and Its Auxiliary Rooms. — Note the absence of 
any swinging- doors opening- into the operating-room, the accessibility of all rooms to 
the surgery, — en bloc, so to speak. 



Furniture Equipment 



179 



thyroid work, and head attachments for cranial work. It should afford 
good drainage for such solutions as are occasionally used in the secondary 
preparation of the patient, and should be equipped with casters of sufficient 
diameter to permit of its being easily moved from place to place, with a lock 
attachment to make it stationary when desired. 

(2) Stands. — These are of regulation style. As a rule two are used, one 
on either side of the operating-table. The stand which is used for sponges 




Illustration XLIV 

An Ordinary Sponge- and Dressing-table. — Note the sterile dressings beneath pre- 
served in their inner wrappers and suspended in a sterile swing-. 



and dressings is generally five feet six inches long by two feet wide, while 
the one devoted to ligatures and instruments is usually about three feet long 
and twenty- two inches wide. (See illustration XLIV and XLV.) 

A much better arrangement is obtained by having two half-circular stands 
which enclose a space around the operating-table. These are six feet long 
on the inner circumference and fifteen inches wide. The surgeon and his 
assistants stand within the circle, the nurses on the outside, yet sufficiently 
close to attend to every want of the operator. If for no other reason these 



180 



Furniture Equipment 



are preferable because they keep the inquisitive visitor from getting too near 
the field of operation; moreover they afford ample table room for single or 
multiple major operations when performed in sequence. The tops and 




Illustration XLV 

An Instrument-stand. — Note the basins filled with sterile water on the shelf 
for cleansing- instruments during- the operation. 



shelves come in three sections, which facilitates their removal for cleansing 
purposes and lessens the expense in case of breakage. 

(3) A washstand with two porcelain basins for the surgeon's use during 
the operation. This is dispensed with if the semicircular stands are used. 

(4) An adjustable instrument-stand which is placed over the patient for 
the convenience of the surgeon. 

(5) An irrigating-stand equipped with rubber casters to facilitate its 
being moved and fitted with glass percolators and rubber-hose attachments. 



/ 






\\ 



/L 



I 



Illustr^ 
The Operating-room. — By referring- to illustration XLIII the relE 




H 



, 



n XLVI 

i of this room to its auxiliary rooms will be appreciated 



Care of Operating-room 181 

(6) An anesthetist's tabic for such articles as may be needed by the anes- 
thetist. 

(7) Two metal stools, one for the anesthetist and the other for the 
surgeon. 

(8) A waste receptacle for soiled sponges, etc., constructed of steel and 
with rubber casters, the cover of which is operated by a foot lever. 

(9) The necessary number of basins and pitchers, generally six of each. 
(See double-page illustration XLVI.) 

Care of the Operating-room. — It is of the highest importance that this 
room and its furniture be kept in the most aseptic manner. Investigations 
indicate that strict attention should be given the condition of the walls and 
floor of this apartment. The walls and ceiling should be thoroughly 
cleansed with soap and water at least every tzvo weeks; the floor mopped 
carefully with corrosive-sublimate solution 1 :1000, or carbolic-acid solution 
1 :20, every morning previous to operating, and with plain water between 
operations unless pus has been encountered, — then rely on one of the above 
disinfectants. 

The tables, stands, etc., should be washed with water and one of the 
numerous soap-powders which are found on the market, then carefully 
rinsed and dried after operative procedures are completed for the day. 

The basins and pitchers are cleansed in the same manner, then stored. 
An extra supply of these utensils should always be kept on hand. 

The instruments should be carefully washed with soap and water after 
each operation; if rusted they should be scoured with sapolio, rinsed, and 
dried. Hemostats and scissors should be taken apart before going through 
this process and finally paired before being returned to their case. Cutting 
instruments must be kept sharp. No one thing interferes with the efforts of 
a surgeon as much as dull knives and scissors. The needles are cleansed in 
a similar manner, scoured with emery dust if rusted, the eyes and points 
inspected, assorted, and placed in their respective glass containers. 

The bone drill, electric cautery, and portable hand reflector should be 
under the supervision of the head nurse, whose duty it is to see that they are 
kept in perfect condition ; it is exasperating to have occasion to use one of 
these instruments and find they are not in service. 

The bottles containing the various drugs which are used in the operating- 
room, but which are kept in the sterilizing-room, should receive daily atten- 
tion by being cleansed with gauze moistened in some antiseptic solution. 

Surgeon's and Nurses' Dressing-rooms. — A similar architectural con- 
struction is followed in these rooms as heretofore suggested. These apart- 



11 







T 




Illustration XLVII 

Surgeon's Dressing-room. — By referring- to illustration XLIII the relation this 
room bears to the operating-room will be seen. 



(182) 



;'7Yfn 




Illustration XLVIII 

Nurses' Dressing-room. — By referring- to illustration XLIII the relation this 
room bears to the operating-room will be seen. 



(183) 



184 Furniture Equipment 

ments should also connect with the operating-room. (See illustrations 
XLVII and XL VIII.) 

Furniture Equipment for Each Room. — (1) A large porcelain (vitreous 
china) sink with several faucets connected with hot and cold sterile -water 
under foot control. 

I must be pardoned for not agreeing with the usual advice given in every 
text-book on hospital equipment, in preferring the porcelain sink I have 
described above to individual basins with the multiplicity of traps, faucets, 
etc., with which they are equipped. The increased mechanism makes them 
more difficult to keep clean than one large open sink. I also desire running 
water during the process of hand sterilization, and not use same water over 
and over again as is commonly seen when the individual-basin system is 
employed. Skin sterilization depends on dilution more than anything else. 

(2) A small aseptic table for the soap and brushes should be within easy 
access to the sink. 

(3) A large table for the packages containing the sterile gowns, suits, etc. 

(4) Clothes-hangers for the surgeons' coats and nurses' uniforms. 

(5) A shower bath is a refinement which the surgeon appreciates in his 
apartment. 



LECTURE XX 

TECHNIC OF THE OPERATING-ROOM 

In previous lectures I have given you the cause and nature of infection, 
and the artificial means employed to prevent it; the principles of asepsis 
and antisepsis ; the value of sterilization ; the best methods for preparing the 
various dressings and other materials used in surgery, I have described the 
operating-room, its furniture, and the care which should be bestowed on this 
apartment to keep it to the highest standard of surgical cleanliness. I have 
described the means employed by different operators for the sterilization of 
hands. I have given each succeeding step in the preparation of the patient 
who is to undergo a surgical operation. I desire now to put into practical 
use the knowledge thus gained by starting the "machinery" of the oper- 
ating-room.* 

As a rule three nurses are assigned, the head operating-room nurse and 
the first and second assistants; the latter is called the "non-sterile nurse," 
inasmuch as she will be called upon to perform such duties as prevent her 
from maintaining a sterile toilet. 

Nurses' Preliminary Toilet. — Probably an hour before the operating- 
room is required, the nurses adjourn to their dressing-room and prepare 
their personal toilet as follows : 

(1) Remove hospital uniform. 

(2) Assume sterile gown. 

(3) Adjust head covering. 

(4) Cleanse hands according to one of the methods described. 

(5) Put on one pair of rubber gloves. (The non-sterile nurse is exempt 
from this step.) 

The operating-room floor has been carefully mopped with mercuric solu- 
tion 1 :1000, or carbolic acid 1 :20, by an orderly properly gowned. 

Preliminary Duties of the Non-sterile Nurse (Second Assistant.) — (1) 

Cleanse all tables and stands with mercuric solution 1 :2000, or carbolic 
acid 1 :20. 



* The student is advised to carefully read the lecture on "The Equipment of the 
Operating-room," to form a comprehensive idea of the various steps suggested in this 
lecture. 

(185) 



186 Preliminary Duties 

(2) With the usual antiseptic solutions cleanse the bottles containing the 
various drugs and stock solutions, glass receptacles which contain other 
articles that may be needed during the operation and place the same on the 
glass table in the sterilizing -room. The following is a practical list : 

(a) Corrosive sublimate tablets for making mercuric solution. 

(b) Ether, or 5-per cent, iodin-benzin compound, or Harrington's solu- 

tion for the final preparation of the field. 

(c) Tincture of iodin. 

(d) Alcohol. 

(e) Carbolic acid. 

(f) Iodoform gauze and tape. 

(g) Drains of assorted sizes. ) , ' , , . . ... . , . 

;f: « . , . > Sterilized and in individual containers, 

(h) Catheters, assorted sizes, j 

(i) Adhesive plaster. 

(3) Remove from the cupboard and place on the glass-top table in the 
sterilizing-room the double-wrapped packages containing sterile dressings, 
sponges, towels, gowns, suits, gloves, celiotomy sheet, etc. 

(4) Loosen the outer wrappers, being careful not to interfere with the 
inner coverings which are sterile. Thus any of these packages may be 
opened during the progress of the operation without the nurse contaminating 
her sterile gloves, which would not be the case if only single wrappers 
were used. (See lecture on "Preparation and Sterilization of Gowns, Dress- 
ings," etc.) 

(5) Sterilize the necessary number of basins and pitchers, together with 
the irrigator (if this latter is to be used). 

(6) The necessary instruments having been selected (this is generally the 
duty of the chief operating-room nurse or first surgical assistant) , they with 
needles and non-absorbable suture material are placed in the appropriate 
sterilizer and boiled. The knives and scissors are cleansed with soap and 
water, dipped in carbolic acid for a few minutes, and placed in a receptacle 
filled with alcohol. 

(7) In an appropriate vessel immerse the hermetically sealed tubes of 
catgut in mercuric solution 1 :2000 until needed. 

Preliminary Duties of the First Assistant Nurse. — 

(1) Cover instrument-stand and sponge- and dressing-table with sterile 
towels. 

(2) Tie a strip of sterile gauze around each of the bottles and glass con- 
tainers which have been selected and cleansed by the non-sterile nurse, and 
place them on the shelf of the sponge- and dressing-table. 



Preliminary Duties 187 

(3) Place the sponges (wipe and abdominal), towels, celiotomy sheet, 
and gloves on the sponge- and dressing-table, still retained within their inner 
cover. 

(4) The dressings, extra sponges, extra towels, extra gloves, etc., are 
located on the shelf of the same stand, preserved in their inner wrappers. 

(5) Take the suits, gowns, and gloves for the surgeon and his assistant to 
their dressing-room. 

(6) Distribute the sterilized basins and pitchers as follows : 

(a) Two or three basins and a similar number of pitchers on the dress- 

ing- and sponge-table, possibly an extra basin and pitcher on the 
shelf of the same. 

(b) Two basins on the shelf of the instrument-stand. 

(c) Two basins on the washstand for surgeon's use during the 

operation. 

(d) Cover all basins with sterile towels until filled with solutions. 

(7) Remove the instruments from the sterilizer and place on the instru- 
ment-stand, together with needles and the different suture and ligature 
materials, and cover with sterile towels. Place the extra instruments which 
have been sterilized for any emergency on the shelf of this table and protect 
in the same manner. 

(8) Adjust the sterile slips to the operating-table pads and remove the 
table to the anesthetizing-room. This is the place to transfer the patient 
from the ward car to the operating-table and not in the operating-room. 

Preliminary Duties of the Head Nurse. — During the various steps which 
have been carried out by the subordinates, the head operating-room nurse has 
supervised the many details and suggested any changes from the general 
routine which she considers beneficial to the case in hand, besides outlining 
the plan of work for the subsequent operations of the day. 

On the arrival of the surgeon there are three procedures that generally 
take place simultaneously — 

(1) The surgeon and assistants repair to their dressing-room, assume 
operating suits and shoes, and sterilize hands. 

(2) The chief operating-room nurse and first assistant adjourn to their 
apartment, change gowns, and sterilize hands. The former assumes two 
pairs of gloves, the latter one pair of gloves and bib-apron ; they then return 
to the operating-room. 

(3) The patient has been brought from the ward and is being anesthetized 
on the operating-table. If ether or chloroform is the anesthetic of choice, 



188 Final Duties 

this is accomplished in the anesthetizing-room ; if nitrous oxid-oxygen, the 
administration occurs in the operating-room. 

Celiotomies. — Inasmuch as the majority of major operations occur in this 
region, I will give you the routine to be carried out to perfect the technic of 
such an operation. 

Final Duties of the Non-sterile Nurse. — After the patient is anesthetized 
the non-sterile nurse carries out the following schedule : 

( 1 ) Remove the ward blanket and sheet which cover the patient. 

(2) Secure the patient's hands to the sides by the use of towels folded 
lengthwise, four-ply : one end of the towel is wrapped around each wrist two 
or three times, the other end is tucked under the buttocks. Thus the weight 
of the body holds them in place ; or the hands are held by straps attached to 
the operating-table. 

(3) Fold the nightgown upward on the chest. 

(4) Cover the thorax with one of the small blankets prepared for that pur- 
pose and adjust the other over the lower extremities within a short distance 
of the pubis.* (Some operators require these blankets covered with rubber 
sheeting.) 

(5) Resterilize hands, assume sterile gloves and bib-apron. 

(6) Assist surgeon in assuming gown and gloves. 

(7) Be prepared to lend such assistance as may be needed during the 
operation. 

The patient, being anesthetized, is wheeled from the anesthetizing-room 
into the operating-room if ether or chloroform has been administered, but 
where nitrous oxid-oxygen is the anesthetic the administration is accom- 
plished in the surgery. 

Final Duties of the Head Nurse. — 

(1) Remove the protective dressings from the field of operation and 
place them in the waste receptacle. 

(2) Make the final preparation of the field according to the method of 
the individual operator. The majority of surgeons at the present time rely 
solely on sponging the field with 

(a) Ether or alcohol and finally painting the same with tincture of 

iodin ; or, 

(b) Harrington's solution, neutralized with alcohol, and finally painting 

with tincture of iodin ; or, 



* Note the protective dressings employed at the primary preparation of the field have 
not been disturbed. 



Final Duties 



189 



(c) Employing a 5-per cent, iodin-benzin mixture. Any one of the 
three methods is efficient. 

(3) Carefully cover the blankets (or the rubber sheets if these are used) 
with sterile towels moistened in mercuric solution 1 :2000. 

(4) Cover the patient and table with the celiotomy sheet, the aperture in 
which corresponds with the field of operation. (See illustration XLIX.) 

(5) Assist in placing the patient in the required position. 




Illustration XLIX 

A Celiotomy Sheet which is draped over the blankets, patient, and table 
immediately before the operation is begun. Note the opening- in the 
celiotomy sheet through which the operation is made. 



(6) Remove outer pair of gloves and assume bib-apron. 

(7) Assume position at the instrument-stand and carry out the following 
duties daring the operation: 

(a) Cleanse blood-stained instruments. 

(b) Have pus-besmeared instruments resterilized before being returned 

to the instrument-stand. 

(c) Prepare sutures and ligatures the desired length, thread needles 

and mount them in their holders or arm ligature-carrier ready 
for use. 



190 



Final Duties 



When needed by the surgeon the handles of these instruments are pre- 
sented and not the jaw of the needle-holder, or the transfixion part of the 
carrier. Such an error mars the surgical reputation of the nurse and grates 
on the sensibilities of the surgeon. 

The head nurse has been chosen to look after the sutures, ligatures, and 
needles because she is familiar with the technic of the individual operator. 
All surgeons have their own ideas along these lines, some use catgut of 
various sizes for different steps, while others employ one standard size for 
everything. Some operators prefer a long ligature, while others claim a 
short strand is easier tied. Some close the abdomen by the "tier method" — 
that is each tissue entering into a wound is stitched separately, tier by tier; 





Illustration L 

The proper manner in which needles should be threaded before being- placed in the 
needle holder and passed to the surgeon. The first picture shows a single 
strand of catgut tied in the eye of the needle. The second illustrates silkworm 
gut twisted on itself, while the third shows a double strand of catgut clamped 
at the ends to maintain an equal length. 



while others use a "through-and-through" suture and close the incision c! cn 
masse" so that it is necessary for a nurse with large experience to be in- 
trusted with this important duty. In a general hospital where several sur- 
geons use the same operating-room and nurses, a standard size and kind of 
suture material should be agreed upon. I use No. 1 chromocized catgut for 
everything, except cosmetic surgery of the face. This simplifies matters and 
is conducive to rapid work. (See illustration L.) 

Final Duties of First Assistant Nurse, — 

(1) Remove inner covering from wipe and abdominal sponges and towels. 
The dressings remain in their inner wrappers until needed. 

(2) Count abdominal sponges and have the same checked by the head 
nurse. This is the fourth time these articles have been counted. 



The Operation 191 

(3) Place abdominal sponges in one of the basins on the sponge- and 
dressing-table. 

(4) Prepare solutions. These have been left to the last so as to be warm 
when needed. The following will be required : 

(a) Normal saline solution in the basins and pitchers on the sponge- 

table to be used for cleansing the sponges. 

(b) A similar solution in the basins on the shelf of the instrument- 

stand for cleansing the blood-stained instruments. 

(c) Normal saline solution in one of the basins on the surgeon's wash- 

stand, mercuric solution 1:2000 in the other. (I prefer Har- 
rington's solution in this latter basin.) 

(5) Assume position at the sponge- and dressing-table and handle the 
sponges during the operation by observing the following rules : 

(a) Keep the solutions warm and clean, not cold and bloody. 

(b) Cleanse each sponge before it is used again. 

(c) Always have a sponge ready for immediate use, so as not to retard 

the surgeon. 

(d) All sponges soiled with pus are thrown in the waste receptacle 

and not returned to the sponge-basin. 

(e) Have an ample supply of extra sponges ready for use in cases com- 

plicated with pus or severe hemorrhage. Extra sponges which 
arc called into service must be counted and finally checked by the 
head nurse before being used. 

(f) Keep an accurate count of all sponges. 

The first assistant nurse has been selected to perform the duties assigned 
her because she appreciates surgical cleanliness, and realizes the necessity of 
maintaining a condition of sterility throughout the operation. Her expe- 
rience in the various steps in the operating-room qualifies her to preside over 
the sponges, — a task of no mean importance. 

The Operation. — For the sake of illustration suppose the case in hand is 
one of pelvic disease. The patient is in the Trendelenberg posture; the sur- 
geon stands on one side of the table, the first assistant opposite. On the 
adjustable instrument-stand (which is conveniently located over the patient) 
have been placed hemostats, knives, and scissors, together with a few dry 
wipe sponges for cleansing the abdominal wound. 

After the incision is made the wipe sponges are immediately removed by 
the assistant and placed in the waste receptacle, not thrown on the floor as is 
occasionally done. Some surgeons use the ordinary abdominal sponge to 



192 The Operation 

cleanse the incision instead of the small wipe sponge, but this can hardly be 
considered good technic. 

Abdominal sponges are now introduced within the peritoneal cavity to 
retain the intestines in the higher abdomen and protect this cavity should 
infection be encountered in the pelvis, besides affording a clear field for oper- 
ative interference. 

Such organs as are diseased are removed, blood-vessels ligated, and the 
intra-abdominal wound repaired. It is just at this point that the experi- 
enced head nurse handling the ligatures and sutures becomes an asset to 
the surgeon. If she is acquainted with his technic she anticipates the length 
of suture necessary, whether single or double, and the kind of needle which 
is desired, thus relieving the surgeon of that detail. The best operator 
appears as an amateur with inexperienced assistants. On the other hand 
the mediocre surgeon with well-trained help accomplishes feats beyond his 
natural dexterity. 

The intra-abdominal portion of the operation being accomplished the sur- 
geon removes all sponges from the cavity and inquires from the sponge 
nurse if the count is correct; she at once enumerates them and replies, a 
check being made by the head nurse, who for the moment leaves her posi- 
tion at the instrument-stand. Thus these articles have been counted six 
times. 

The abdomen is now closed according to the individual method of the sur- 
geon. The surgical assistant cleanses the abdominal incision and dries the 
patient's back. The sponge nurse has the dressings (abdominal outfit) ready 
which are then applied as follows : 

(1) The fluffy gauze covers the field of operation. 

(2) Cotton-gauze pads cover this dressing. 

(3) The abdominal binder is adjusted. (See lecture on "Preparation and 
Sterilization of Gowns, Dressings," etc., section "Bandages.") 

The non-sterile nurse in the meantime has obtained a nightgown and 
blankets from the warm closet in the anesthetizing-room. The gown is sub- 
stituted for the one the patient wore during the operation; the blanket is 
wrapped around the patient, and the transfer from the operating-table to 
the wheel car is made. This is the proper place for a change of clothing, — 
the temperature of the room is appropriate and the gown can be easier ad- 
justed than when in bed. The patient is then returned to the ward or room. 

In my opinion the routine outlined above is near the ideal for the following 
reasons : 

(1) The transfer of the patient from the wheel car to the operating-table 
is made in the anesthetizing-room before the anesthetic is begun. 



Modifications of Teciinic 193 

(2) The patient is kept comparatively dry throughout the operation. If 
the plan of deluging the patient with large volumes of soap and water in the 
final preparation is carried out, the following is the result : 

(a) The patient lies on a wet bed during the operation. 

(b) This adds to the reduction of body-temperature, which the opera- 

tion is also influencing. 

(c) Hence, it lowers body-resistance and invites shock. 

(d) The operating-room was never intended as a lavatory. 

(3) The nurses have been chosen for their duties because of their indi- 
vidual qualifications. 

Modifications of Technic for Special Locations. — 

( 1 ) Operations on the Head. — The Hartley position is employed to facili- 
tate venous return. (See illustrations XXVI and XXVII.) In addition 
some form of head rest is utilized, every surgeon having some special device. 
After the final cleansing of the field, which is the same as in other locations, 
the head nurse covers the scalp with two- or three-ply gauze (20 by 24 
mesh) held in place and kept smooth by an elastic tourniquet, which also 
prevents hemorrhage from the scalp, — a field where the blood-supply is very 
rich. Before operative procedures are begun the surgeon cuts an opening 
through the gauze corresponding to the size and location of the field. This 
extemporized gauze skull-cap is simply another means to prevent contamina- 
tion of the hands of the operator, even though the scalp has been shaved 
and the field passed through a most thorough process of sterilization. In 
cases where only a local depilation has been made as in operations for mas- 
toid disease, I prefer a rubber cap such as can be purchased at any instru- 
ment store. This protects the hair from blood-clots and is self-retaining. 
It is sterilized like other rubber goods. 

The sponges used in intracranial operations are small pledgets of gauze 
made at the time, and so folded as to practically conceal all loose fibers of 
the material. Hemostats are attached to facilitate their use. An ample 
supply is necessary, as venous oozing is generally very profuse. Prepared 
cranial sponges in small resections of the skull are clumsy, although pos- 
sessing the advantage of having no raw edges. In nearly all cases the 
ordinary wipe sponge is out of proportion except for the scalp incision. 

The administration of an anesthetic in operations on the brain is accom- 
panied with more danger than in surgical procedures in other locations. 
Shock is liable to manifest itself suddenly, and respiration cease without 
warning. The anesthetist therefore should provide an artificial-respiration 
apparatus as well as a sphygamomanometer, which latter instrument should 
be used throughout the operation by a special assistant, whose further 



194 



Modifications of Technic 



duties will be to operate the artificial-respiration apparatus if occasion de- 
mands. For as Cushing remarks in this connection, "breathing stops long 
before cessation of the heart-beat, which under artificial respiration may be 
kept up indefinitely. A number of patients have been rescued in this way." 

(2) In operations on the neck, such as for goiter, the Hartley position is 
utilized together with a neck elevator. (See illustration XXVI.) This ex- 
tends the neck, convexes the field of operation, and throws the gland more 
prominently forward. The final preparation of the field is the same as has 
been described for celiotomies. The ordinary wipe sponges are used. Plain 




Illustration LI 

The Lilienthal Elevator in Position. — This elevator is used in operations on the 
liver and upper zones of the abdomen. 



sterile-gauze dressings are employed, held in place by a roller bandage. The 
bandage must not be snugly applied, as the pressure thus exercised may pro- 
duce ill effects. Compression will force an abnormal amount of thyroid 
secretion into the circulation, and jeopardize the life of the patient. 

(3) Operations on the Liver, Gall-bladder, and Hepatic Ducts. — The pa- 
tient is placed supine on the table, in such a manner that the Lilienthal eleva- 
tor corresponds to the posterior site of the liver. The elevator is then raised 
to a sufficient height to produce a convexity of the upper abdomen. The 
liver is thus forced forward. If the head of the table is elevated slightly 



Modifications of Technic 



195 



the intestines gravitate to the lower abdomen. This method greatly facili- 
tates the subsequent steps of the operation. (See illustration LI.) The final 
preparation of the field is the same as recommended for celiotomies. Ordi- 
nary abdominal sponges are employed for the work within the peritoneal 
cavity. Wipe sponges are used for the abdominal incision. If the operation 
is on the gall-bladder or ducts, a rubber drainage-tube is inserted and 
stitched in place with catgut. Occasionally a cigarette drain is used to afford 
a means of escape for fluids beneath the liver. 




Illustration LII 

The Cunningham FJlevator in position for operations on the kidney. Note the 
padded standard at the back. A similar one is also used in front, by which 
means the patient is retained in position. 



Dressings are applied as for any other abdominal operation, unless a drain 
is employed, in which case the following modifications are made : 

(a) Fluffy gauze is so placed on the wound as to permit an exit to the 

drainage tube. 

(b) A portion of gutta-percha tissue or oiled silk of sufficient size to 

cover the fluffy-gauze dressing is next applied, an aperture being 
made through this protective to accommodate the passage of the 
drain. 



196 Modifications of Technic 

(c) Cotton-gauze pads are next adjusted. 

(d) Finally the abdominal binder is utilized to hold the dressings in 

place, the tube being allowed to protrude through it. Gutta- 
percha tissue or oiled silk is used in an endeavor to prevent the 
outer dressings from becoming soiled with the discharge. Fre- 
quently a dermatitis is produced by the excretion. When this 
complication occurs some demulcent, such as the officinal oxid of 
zinc ointment, is applied to the skin. 
After the patient is returned to the ward, the drain which projects from 
the wound and through the dressings is attached to a longer tube and con- 
veys the discharges to a bottle suspended at the side of the bed. I may add, 
a similar procedure is instituted when drains are utilized in the urinary 
bladder. 

Where the operating-table is not equipped with a Lilienthal or Cunning- 
ham elevator, or in private practice where an extemporized operating-table 
is utilized, sand bags are employed to produce the necessary elevation, but 
as can be easily understood they are inferior to the mechanical appliances 
spoken of. 

(4) Operations on the Kidney. — One of the most difficult steps in opera- 
tions on this organ is to secure a proper adjustment of the patient on the 
table. The Cunningham elevator which is used must be adjusted to the cor- 
rect height, and the pressure of the elevator manifested in the right place, 
so as to lengthen the distance as much as possible between the last rib and 
the crest of the ilium — in other words, to increase the "working space." For 
the sake of illustration, suppose the right kidney is to be operated on. The 
patient is placed on the left side in such a manner that the top of the elevator 
will be just below the last rib; the trunk is slightly inclined to the surface of 
the table, and held in this position by heavy vertical padded standards 
attached to the Cunningham elevator, which is then raised. If the elevator 
is too high the muscles on the right side will be on such an excessive tension, 
as to interfere with the necessary manipulations ; if not sufficiently elevated, 
the "working space" is not increased to a satisfactory extent. (See illustra- 
tion LII.) The final preparations are the same as advised for celiotomies. 
An abdominal sponge or two may be required to place under the kidney after 
it is loosened from its bed and during operative interference. A cigarette 
drain is usually necessary, in which case the protective oiled silk is used to 
prevent the outer dressings from becoming soiled. Celiotomy dressings held 
in place by the usual binder are used. 

Operations on the Vagina. — The patient is placed in the dorsosacral or 
lithotomy posture (see illustrations XXIII and XXIV) on a Kelly pad, pro- 



Modifications of Technic 



197 



vision being made for drainage. Some operating-tables are so constructed 
as to obviate the necessity for such a pad. 

The secondary preparation of the vagina is best accomplished by thor- 
oughly mopping the canal with Harrington's solution, neutralizing the same 
with alcohol, and finally irrigating with sterile water. I have no hesitancy 
in recommending this technic, as I have put it to some very severe tests. 







Illustration LIII 

A Lithotomy Sheet used as a protective covering- in 
operations on the vagina, rectum, and perineum. 



The usual method is by using a wipe sponge saturated with tincture of 
green soap and water to thoroughly cleanse the canal, followed by a douche 
of a 2-per cent, carbolic-acid solution. 

A simple form of covering for a patient in a lithotomy posture is an 
ordinary muslin sheet in which three holes have been made; the center one 



198 Modifications of Technic 

corresponds to the field of operation, whether it be the vagina, the rectum, 
or the perineum; to the lateral openings are sewed stockings made of a 
similar material to the sheet. After the patient is in the lithotomy posture, 
and the necessary cleansing of the field has been accomplished, this cover 
is applied by pulling on the stockings and draping the sheet around the sub- 
ject. (See illustration LIII.) 

After all I know of no better form of covering yet devised for protecting 
the patient than towels appropriately draped over the buttocks and extremi- 
ties, the latter of course being previously covered with the long canton- 
flannel stockings with which the patient comes to the operating-room. The 
advantage is, when soiled these towels are easily replaced. Wipe sponges 
are used. The packing, if any is employed, should be iodoform gauze, be- 
cause being an antiseptic it retards bacterial development in a very fertile 
field. The external dressings consist of a cotton-gauze pad held in place by 
a "T" bandage. 

General Remarks. — The same aseptic care must be exercised in all opera- 
tions. I am sorry to say there is an erroneous impression prevalent that if 
the peritoneal or cranial cavity is not the field for surgical interference, a 
high standard of asepsis need not be maintained. This is wrong. Pathogenic 
bacteria lurk everywhere. Fearful infections can occur in any tissue through 
lack of surgical cleanliness. If the truth were told, it would be proper to 
say that the abdominal serosa (peritoneum) can withstand more abuse and 
insults from a faulty technic than any tissue in the economy. Therefore, 
if it is entitled to the care generally bestowed on it, then other fields of 
operative interference should receive at least the same consideration. This 
is especially true of operations involving the joints where susceptibility to 
infection seems to be at the maximum. As trained nurses you should per- 
form your duties in a thorough and painstaking manner, regardless of the 
nature of the operation. 



LECTURE XXI 
THE EMERGENCY OPERATING-ROOM 

In every modern hospital an emergency operating-room is equipped for 
the care of such patients as have been injured. It would be inappropriate 
to take care of this unfortunate class in the general operating-room where 
celiotomies and cranial operations are performed daily. This emergency 
surgery must be kept to the highest standard of efficiency because this class 
of patients enter under the most unfavorable conditions. Nothing about 
them is sterile, they have suffered more or less shock, possibly they are de- 
pleted of blood, and often are so badly mangled as to necessitate major oper- 
ations. Under such exigencies the nurse must play her part in the deftest 
manner, because this is vastly different from a planned operation where 
everything is sterile and in order, moving with clock-like regulation. 

Emergency Operating-room Equipment. — The architectural construc- 
tion is the same as that of the main operating-room, but very rarely is there 
a sterilizing- and anesthetizing-room connected with it ; consequently, besides 
the regular equipment, additional furniture is needed so as to have all acces- 
sories concentrated in one room. Moreover a sterilising outfit for water 
and a combination sterilizer for basins, pitchers, and instruments must be 
included. Time, which plays an important factor in emergency cases, is not 
to be lost. This room should always be kept to the highest point of 
efficiency. The additional furniture should consist of — 

(1) An aseptic cupboard similar to the one described in the main ster- 
ilizing-room, for the storage of sterilized articles such as dressings, sponges, 
gowns, operating suits, caps, gloves, etc., besides clean blankets, rubber 
sheets, Kelly pad, hot-water bottles, etc. 

(2) A four-shelf glass aseptic stand, a duplicate of the one in the main 
sterilizing-room, on which is kept the following : 

(a) Stock solutions and mixtures. 

(b) Drugs and antiseptics. 

(c) Medicated-gauze preparations, as iodoform gauze and iodoform 

tape. 

(199) 



200 Duties of Non-sterile Nurse 

(d) Roller bandages and adhesive plaster in various widths. 

(e) Basins and pitchers. 

(f) Accessories such as urethral catheters (assorted sizes), drainage 

tubes (assorted sizes), stomach tube, complete infusion outfit 
with the necessary flasks of sterile normal saline solution. All of 
these accessories are sterilized and preserved in the manner pre- 
viously described. 

(g) Hypodermic syringe, needles, and tablets. 

(3) A stand for the ordinary anesthetics with appropriate cones and in- 
halers, and a complete nitrous oxid-oxygen apparatus with extra tanks of 
these gases. 

(4) A surgical-instrument case similar to the one in the main sterilizing- 
room filled with such instruments and mechanical accessories as are em- 
ployed in emergency work. 

Maintaining the Equipment and Efficiency. — After every operation any 
depletion in these stock supplies should be immediately replenished, and all 
instruments cleansed and replaced in the instrument-case; tables thoroughly 
sponged with the usual antiseptic solutions, dried with sterile towels, and 
covered with sterile sheets, which can be removed at a moment's notice; 
basins and pitchers sterilized and placed on the accessory-stand upside 
down; finally the floor mopped with mercuric solution 1:1000, or carbolic 
acid 1 :20, and the apartment closed. 

Emergency Operating-room Technic. — By way of illustration, suppose 
the case in hand is one of a mangled thigh. The patient is placed on the 
operating-table by the ambulance corps and the house surgeon notified, 
who will 

(1) Observe if hemorrhage is present, and check the same temporarily if 
possible. 

(2) If the patient is conscious and suffering severe pain, order morphin 
and atropin administered, or other narcotics. 

(3) Ascertain the character of the pulse and order stimulants if neces- 
sary. These may include besides the ordinary heart stimulants transfusion 
or intravenous infusion of normal saline solution with adrenalin. (See lec- 
ture "Transfusion — Infusion.") 

With these several factors under control the surgeon adjourns to the 
dressing-room and prepares his toilet. 

Duties of Second Assistant, or Non-sterile Nurse. — 

(1) Protect uniform with a gown (not necessarily a sterile gown). 

(2) Remove soiled clothing from patient, cutting the same if necessary. 



Head Nurse — First Assistant 201 

(3) Adjust clean nightgown to patient and maintain body-temperature 
with warm- water bottles and blankets, so arranged as to leave the injured 
area exposed. Cover the blankets with rubber sheeting. 

(4) Remove soiled clothing from the operating-room.* 

(5) Assume sterile gown and cap, sterilize hands, adjust gloves and bib- 
apron — await further orders. 

Duties of Head Nurse. — During the time occupied by the non-sterile 
nurse in changing the patient's clothing, supplying artificial heat, etc., the 
head nurse should carry out the following duties : 

(1) Adjust cap, assume gown, sterilize hands, and put on two pairs of 
gloves. 

(2) Place Kelly pad under the injured member, shave and mechanically 
cleanse the field of operation; rinse with sterile water, remove Kelly pad. 

(3) Protect the member above and below the field of operation with 
sterile towels moistened in mercuric solution 1 :2000. Arrange sterile towels 
moistened in a like solution so as to cover the protective rubber sheeting. 

(4) Remove outer pair of gloves and assume bib-apron. 

(5) Complete sterilization of the field according to the views of the indi- 
vidual surgeon. 

(6) Take position at the instrument-stand and have sutures and ligatures 
ready. 

Duties of First Assistant Nurse. — 

(1) Select instruments and place in the sterilizer, together with the neces- 
sary number of basins and pitchers. 

(2) Remove coverings from the various tables and stands in the 
operating-room. 

(3) Loosen outer coverings of dressings, towels, sponges, etc., without 
touching inner wrappers. Allow them to remain in the dressing cupboard 
temporarily. 

(4) Assume cap and gown, sterilize hands, adjust a pair of gloves, and 
bib apron. 

(5) Remove from the cupboard the dressings, towels, sponges, etc., still 
preserved in their inner wrappers and place them on the shelf of the sponge- 
and dressing-table. 



* Anesthetization of the patient is now begun. Nitrous oxid-oxygen is the anesthetic 
of choice. (See lecture "Anesthesia — Anesthetics," section "Indications and Contra- 
indications for Nitrous Oxid-Oxygen.") 



202 Emergency Patient 

(6) Remove inner covering from a package of towels. Use as many as 
are necessary to cover the sponge- and dressing-table and instrument-stand ; 
place the remainder on the sponge- and dressing-table. 

(7) Distribute the sterilized basins and pitchers as for a planned 
operation. 

(8) Place sterilized instruments, with ligatures and sutures on the instru- 
ment-stand. 

(9) Fill basins and pitchers with solutions similar to those described for 
use in the main operating-room. 

(10) Remove the inner wrapper of the sponges and submerge these 
articles in one of the basins on the sponge- and dressing-table. The dress- 
ings are allowed to remain in their original wrappers until needed. 

(11) Remove outer pair of gloves and adjust bib-apron. 

(12) Take position at sponge- and dressing-table and be ready to handle 
sponges and dressings. 

Thus each nurse has specific duties to perform ; no time is lost. This is as 
it should be. The well-trained nurse is a disciplined soldier. There is no 
need for the hurry and panic that are so commonly seen even in hospitals 
where emergencies are frequent. The fault lies in lack of discipline, lack 
of attention to detail, lack of method — and the consequence is the patient 
suffers because of a lack of organization. 

The Emergency Patient. — The victim of an accident is not prepared for 
a surgical ordeal ; the intestinal tract has not been emptied, possibly the 
emergency occurred soon after a meal and hence the stomach has not had 
time to expel its contents; possibly, too, the subject is an alcoholic, or a 
sufferer from chronic Bright's disease, none of which conditions has been 
investigated. Such a patient deserves the closest attention and care, both 
at the time of operative interference and after. From the very nature of 
things the greatest antiseptic precautions should be taken. 

Immediate Complications. — 

(1) Vomiting. — Because of having received no preparatory treatment, 
this symptom may give a great deal of trouble during the administration 
of the anesthetic, especially if ether or chloroform is employed. Frequently 
it is desirable to lavage the stomach before beginning the operation, unless 
the accident is a penetrating wound of the abdomen : under such conditions 
this step should certainly be omitted, because should the stomach have been 



Splints and Artificial Supports 203 

punctured it will only cause a dissemination of infectious material through- 
out the peritoneal cavity. 

(2) Shock and Hemorrhage. — Both of these conditions have been ex- 
plained and the treatment given in the lectures devoted to these subjects. 

Later complications are dealt with in the lecture devoted to ''Some Post- 
operative Complications." 

Room Assigned for Splints and Other Artificial Supports. — Adjacent to 
the emergency operating-room there should be a small room or closet set 
•apart in which to store splints and the various materials from which they 
are made, extension apparatus, plaster of Paris in bulk, plaster-of-Paris 
bandages, silicate of soda, etc. (See lecture on "Fractures," section "Dress- 
ings Employed.") 



LECTURE XXII 

PRINCIPLES AND PRACTICE OF POSTOPERATIVE 

NURSING 

Following operations of any magnitude there is always more or less de- 
pression, due to the influence of the anesthetic and the debilitating effects 
of the surgical procedure, — in some cases shock is present. 

Assignment of Nurse. — As a preparatory measure the supervising nurse 
of the floor to which the patient belongs assigns one of her assistants, whose 
duties will be the following : 

(1) To ascertain the position in bed the surgeon desires the patient to be 
placed after the operation, and arrange the bed accordingly. 

(2) To obtain the surgeon's views with regard to the use of morphin if 
the patient suffers severe pain, and his wishes as to the time to administer 
water. 

(3) To remain at the bedside until the patient becomes conscious. 

(4) To prevent any unnecessary movements. 

(5) To keep the patient covered. 

(6) To lend such help as is necessary during the stage of nausea and 
vomiting. 

(7) To count the pulse every half hour, note its character, and take the 
temperature every two hours, carefully charting both signs. 

(8) To observe the respirations, if free and easy, or labored and sighing, 
or impeded ; if the latter, and the character of the pulse and temperature are 
satisfactory, it is due to a constriction of the larynx. Under such circum- 
stances grasp the lower jaw and pull it forward and upward. 

(9) To remove the artificial heat when proper reaction has occurred. 

(10) To add such comforts as come within her province. 

Positions of Patient in Bed Immediately Following Operation. — The 

position the patient is to assume in bed depends on three factors — 

(1) The nature of the operation which has been performed. 

(2) The individual views of the operator. 

(3) The condition of the patient. 

(204) 



Positions Following Operations 205 

Celiotomies (Abdominal Operations). — Some operators utilize the Fow- 
ler position from one to three days after all abdominal operations, ex- 
cepting in cases complicated with shock ; maintaining, and correctly so, 
I think, that even though there is no suppuration, no apparent infection 
present, the operative procedures may have set free latent microorganisms, 
or during the operation bacteria may have been introduced, and hence to 
be conservative this position is used in all cases for the first day or so. 
These operators base their reasons for considering this posture after ab- 
dominal operations less hazardous for the patient upon certain well-known 
anatomic and physiologic principles which I have already mentioned when 
speaking of the Fowler position, viz. — 

(1) There is a constant peritoneal current from the pelvis to the 
diaphragm 

(2) The nearer the erect position of the body, the more is the current 
retarded. 

(3) The pelvis contains comparatively few lymphatics, therefore absorp- 
tion is slow at this point. 

(4) The region beneath the diaphragm is richly supplied with lymphatics, 
and absorption is consequently rapid in this locality. 

(5) Hence, the elevation of the trunk of the body (Fowler's position), 
slows the peritoneal current, and any infection in the lower abdomen is 
retarded in its progress toward the rich absorbing fields beneath the 
diaphragm. The patient therefore is not suddenly swamped by a rapid ab- 
sorption of infection, but sufficient time is given the economy to increase the 
resisting power and offset the invasion. (See lecture on "Positions or 
Postures of the Patient Utilized in Surgery.") 

Other surgeons are satisfied to allow the patient to assume the ordinary 
flat recumbent positioji after abdominal operations, and only utilize the Fow- 
ler posture when the case is one of suppuration or acute infection is known 
to be present. 

Extremities — Thorax — Cranium. — After most operations on the extremi- 
ties the Hat recumbent position is universally selected. In certain cranial 
operations Fowler's posture is utilized to assist in checking venous oozing, 
etc., while in surgery on the thorax for the removal of fluids, this position 
is used to assist drainage. 

In cases complicated with shock or hemorrhage all surgeons require the 
elevation of the foot of the bed 30° to 45°, without regard to the kind of 
operation, to assist the demoralized circulation and maintain blood-pressure 
around the vital centers in the brain. (See lectures on "Surgical Shock" 



206 Positions Following Operations 

and "Hemorrhage.") Thus I may say there are three positions in which 
the patient may be placed after an operation — 

(1) The head-up or Fowler's position. 

(2) Head-down or foot-elevated position. 

(3) Flat recumbent position. 

Preparation of the Fowler Position. — The various mechanical means em- 
ployed to obtain this position have already been given in the lecture devoted 
to "Postures or Positions of the Patient Utilized in Surgery." (See illustra- 
tions XXVIII, XXIX, and XXX.) 

In discussing the further preparation of this position, I shall take the 
liberty to describe the manner in which the Howell bed-frame is used — 

(1) The bed is spread in the usual manner with sheet and draw sheet, 
between which is placed a rubber protective. 

(2) Place the bed-frame on the bed, elevating the back support 35°, the 
foot elevation somewhat less. 

(3) Pad the frame with pillows, and cover with a blanket. 

(4) Place a quilted pad on the blanket at the site of the buttocks. 

(5) Double blankets to serve as a cover for the patient are now placed 
on the frame. 

(6) Between the double blankets and the one used to cover the frame 
locate four or five warm-water bottles (120° to 130°F.) wrapped in towels. 

(7) The patient is laid beneath the double blankets when returned to bed 
and the warm-water bottles rearranged. 

As a substitute for the bed-frame the head of the bed may be raised by 
an elevator similar to the one illustrated in the lecture on "Positions or 
Postures of the Patient Utilized in Surgery." 

Flat Recumbent Position. — Prepare bed in the manner just described, 
omitting the frame and pillows (steps 2 and 3). The objection to pillows 
under the patient's head during the period of unconsciousness is that they 
force the head too far forward on the chest, thus constricting the larynx 
and interfering with respiration*. Pillows may be used, however, when con- 
sciousness returns. 

Head-down or Foot-elevated Position. — Prepare bed as in flat recumbent 
position. Elevate the foot of the bedstead by means of an elevator or sub- 
stitute chairs, blocks, etc. This is the so-called "Shock Bed." (See illustra- 
tion XXXVI.) 

Frequently great comfort is obtained by folding a pillow on itself and 
placing the same beneath the flexed knees. This as you can easily under- 
stand relieves the tension of the abdominal muscles when the case has been 



Artificial Heat — Nausea 207 

a celiotomy, and in operations in other parts it affords a change of position 
and rests the patient. This will not interfere with any of the above postures 
which may have been ordered by the surgeon. The indiscriminate moving 
of the patient from side to side should not be allowed for the first twenty- 
four hours, and not then, if the general condition is unfavorable. 

Artificial Heat. — It is not necessary, in fact it is obviously wrong, to fill 
the bottles with very hot water which are used to stimulate the patient. The 
excessive high temperature thus produced in the bed only causes a further 
depression of the vital forces of the patient, which should not be further 
reduced, but rehabilitated. Serious burns have occasionally been produced 
by these hot bottles coming in contact with the unconscious patient, a very 
deplorable accident, one not easy to conceal, and still more difficult to ex- 
plain to a jury. Such an injury is the result of negligence on the part of the 
nurse who is the agent of the hospital which employs her, and hence, the 
institution is responsible for her careless acts of omission and commission. 
If such an unfortunate occurrence happens in private practice the nurse who 
is in the employ of the family, is personally held responsible and liable for 
damages, even though she was recommended for the position by the surgeon. 
But in either case, for some unknown cause, the patient holds the surgeon 
equally to blame (which of course is erroneous), and everything is done to 
draw him into a lawsuit and injure his reputation. The artificial heat is 
gradually withdrawn as the patient's recuperative powers assert themselves ; 
one by one the bottles are dispensed with, then the blankets which were 
wrapped around the patient in the operating-room are removed until finally 
after twelve or fifteen hours, if there are no contraindications the toilet of 
the bed consists of the usual bedsheet, rubber protective, drawsheet, and a 
blanket and sheet that cover the patient. 

Nausea and Vomiting. — I do not think these distressing symptoms are 
as frequent at the present time as formerly (at least this has been the ob- 
servation in my own practice), since the advent of the expert anesthetist. 
The nicety with which the anesthetic is administered, the care which is ex- 
ercised in not giving any more than is absolutely necessary to keep the 
patient under its influence, is in strong contrast with the deluge of anesthetic 
which was formerly the practice. Moreover since the use of nitrous oxid- 
oxygen is becoming more general, nausea and vomiting are rarely seen. I 
also know positively the thirst after abdominal operations which was a bete 
noire to both surgeon and patient is greatly lessened, and nephritis and 
pneumonia following anesthetics are practically things of the past. Antici- 
pating that nausea and vomiting may ensue, the nurse assigned to the case 



208 Nausea — Pain 

for the first few hours after the operation should have in readiness a basin 
and extra towels to meet this emergency. 

These distressing symptoms as a rule will subside after six or eight hours ; 
but occasionally continue for days, and become a source of great worry to 
the surgeon and exhaust the patient. There are no drugs in use which give 
much, if any relief ; this I say in spite of the numerous remedies which have 
been advised. Lavaging the stomach should be tried. It is hardly neces- 
sary to state that during this stage no fluids should be given by the mouth, 
as they only serve to irritate the already irritated stomach. The intense 
thirst may be somewhat relieved by small pieces of ice placed in the mouth, 
allowed to melt, and then expectorated. If the nausea and vomiting con- 
tinue for days, or the patient becomes exhausted, proctoclysis and nutrient 
enemata must be employed. (See section in this lecture on "Rectal Feed- 
ing/' also lecture on "Transfusion — Infusion," section "Proctoclysis.") In 
exceptional cases when the vomiting is of such severity as to produce dan- 
gerous exhaustion, a full dose of morphin hypodermatically will be ordered 
to afford rest. The sponging of the face and hands and the frequent use 
of some alkaline antiseptic mouth wash such as may be made from Seller's 
tablets, are little niceties which add to the comfort of the patient. In 
abdominal cases if these symptoms have subsided and return after the ad- 
ministration of fluids, it is not always due to the effects of the anesthetic, 
but may be suggestive of infection developing or an obstruction forming, 
especially if accompanied with pain, distention, increased pulse and 
temperature. 

Pain. — The administration of morphin for the relief of pain immediately 
following surgical operations is well indicated. I have frequently referred 
in my lectures to rest as a primary factor in the treatment of all surgical 
cases, — rest to the part which has been injured, rest to the infected area, 
rest to prevent the spread of infection. I desire to impress on you whatever 
means may have been employed to keep the local part at rest are to a great 
extent nullified unless the patient's entire system is placed in the same con- 
dition. There are some surgeons, however, who oppose the use of morphin 
after abdominal operations, claiming that the administration of this drug 
produces nausea and vomiting and encourages constipation and flatus with 
its accompany tympanites (distention of the intestines with gas) — in other 
words, digestive disturbances are the sequence. Personally I much prefer 
seeing the patient rest comfortably under the influence of this drug, allowing 
the nervous system to recuperate from the depression of a surgical operation, 
than tossing wildly in bed from side to side, and thus producing further 
exhaustion. The use of morphin under such conditions is surgical and 
sane. It is your duty to obtain the surgeon's views on the subject before 
administering this drug. If morphin is denied, it is not the nurse's duty to 



Pulse and Temperature 209 

exercise physical force to restrain the patient, as more harm can accrue 
therefrom than if left alone. This is the time for all the gentle tactics a 
nurse possesses. 

In operations in regions other than the abdomen, I do not think there is 
any division of opinion as to the advisability of using morphin for the relief 
of pain immediately following surgical interference. 

Pulse and Temperature. — The pulse and temperature should tend toward 
the normal after any surgical procedure, hence it is an inviolate rule that 
the closest attention be given these two important signs for the first day — 
in fact, from the time an operation has been performed until convalescence 
is established, the patient's condition is fairly gauged by the pulse and tem- 
perature. During the first six hours after operative interference the pulse 
should be counted every half hour and close observation paid to its char- 
acter. If its rate tends to the normal, or at least its frequency is not in- 
creased, and the character of good volume, it may be assumed that the 
patient is recuperating from the depression of the operation, or at any rate 
is not retrograding. // on the other hand the pulse becomes more rapid, its 
volume diminished, and the general character enfeebled, it certainly may 
be concluded that the patient is not rallying from the effects of the opera- 
tion. If in connection with this important sign the temperature is taken 
every two hours (or more frequently if necessary) and the thermometer 
readings indicate that the depressed body-heat (which is common after 
operations) is rising toward the normal in the same proportion as the pulse- 
curve is tending that way, there is a confirmatory indication that the recuper- 
ative powers of the patient are asserting themselves. But if the body- 
temperature is sinking more and more, and the pulse becoming faster and 
faster with decreased volume, there is prima facie evidence that something 
is occurring which should receive immediate attention — probably shock or 
hemorrhage. Because these signs are in a favorable condition when first 
observed is no guarantee they will remain so ; hemorrhage may stealthily 
ensue hours after ; or shock postponed, take place later. Hence, the rule to 
which there is no exception, the patient's pulse should be counted every half 
hour for six hours, the temperature taken three times during this period, 
and for the first day repeated inspections made of the patient to ascertain 
the true condition. This may seem unnecessary, but instances have im- 
pressed me with its necessity. 

A pulse of 100 to 110 and a temperature of 100° F. occurring between 
the second and third day should not as a rule cause any anxiety in a large 
majority of cases — they simply indicate the absorption of some debris 
(septic intoxication). But if such an elevation of the pulse and temperature 
continues from day to day, or increases, it is very suggestive that infection 



210 Water and Nourishment 

is present, especially if accompanied with constipation, headache, and a gen- 
eral feeling of ill being; and in celiotomies distention may be present. The 
sudden advent of a chill with rise in temperature and pulse toward the end 
of the first week is indicative of pus formation, possibly in the incision. 
Pain will be complained of previously in this locality. A careful record of 
these important signs must be made ; days after their occurrence they may 
be the chief aid in the diagnosis of some abnormality that is taking place. 

Respiration. — The respiration should receive careful attention during the 
period in which the patient is unconscious from the anesthetic. On account 
of the relaxation of the muscles of the neck the head falls forward on the 
chest and obstructs the larynx, so that it will be necessary for the nurse to 
elevate the lower jaw and pull it forward, maintaining it in this position 
until the effect of the drug has subsided. Again, the character of the res- 
piration is frequently indicative of the patient's general condition. The deep 
and regular breathing which accompanies a pulse returning to its normal 
rate and a temperature approaching the correct body-heat, is in striking con- 
trast with the shallow, sighing respiration which is a companion symptom of 
the rapid, flickering pulse, and dropping temperature of a patient suffering 
from shock or hemorrhage. A sudden acceleration of respiration accom- 
panied with a rise in temperature and pulse rate in a patient apparently con- 
valescing is very suggestive of a pneumonia developing. After operations 
within the cranium, when everything has been progressing favorably, ster- 
torous (snoring) respiration is frequently the first symptom that attracts 
attention to the patient, and on investigation the other signs of cerebral com- 
pression are noted. 

Water and Nourishment. — Water may be administered by the mouth 
after surgical operations as soon as nausea and vomiting have subsided, 
followed sooner or later by a liquid diet. 

In celiotomies there are two divisions of thought regarding the proper 
time for the administration of water and other liquids. Some surgeons 
insist that water be given the patient as in operations in other regions after 
nausea and vomiting have ceased (excepting in operations on the stomach), 
claiming this is necessitated by the following existing conditions : 

(1) The thirst that follows abdominal operations. 

(2) The diminution of the watery elements of the blood produced by 
the anesthetic (ether or chloroform). 

(3) The loss of animal fluids which may have taken place during the 
operation — that is from the loss of blood, vomiting, etc. 

(4) The irritating effects of the anesthetic (ether or chloroform) on the 
kidneys, which are in many cases laboring under the disadvantage of some 
general infection. 



Water and Nourishment 211 

These surgeons claim the following advantages for the early administra- 
tion of water and other fluids : 

(1) Thirst is relieved. 

(2) The blood compensated for the watery elements lost. 

(3) The kidneys are flushed and assisted in their function of elimination. 

Other surgeons concede these facts, but insist that the time for the admin- 
istration of water and fluids by the mouth is the day previous to the opera- 
tion; or by proctoclysis after operative interference. They anticipate the 
condition the patient will be in after the operation, and prepare for it accord- 
ingly. These operators object to the administration of water by the mouth 
immediately after nausea and vomiting have ceased on the following 
grounds : 

(1) The presence of fluids in the stomach causes increased peristalsis of 
the entire alimentary canal. 

(2) Peristalsis increases the peritoneal current, the very thing which is 
not desired. 

(3) Peristalsis disseminates infection, if this should be present, and trans- 
forms a local into a general infection. 

(4) The first principle in the treatment of infection, and the basic idea to 
prevent it, is rest. Why then increase intestinal action when infection may 
be present by the administration of fluids by the mouth ? 

(5) Being unable to determine in many cases whether or not infection is 
present, the surgeon should treat such cases for the first twenty-four hours 
as though it were. Preventive measures are ideal. 

(6) By the use of Murphy's system of proctoclysis all the fluid the 
system needs can be supplied, and with the minimum amount of peristalsis. 

It is a very simple problem. An inflammatory process (infection) in one 
part of the body should be treated exactly as in another. The kind of tis- 
sue involved does not change the treatment. An infected joint is put at rest, 
or an injured articulation which may become infected is immobilized. So it 
is with the peritoneum; if infection is present it is kept practically quiet by 
administering nothing by the mouth, and inasmuch as operative measures 
may cause this serous tissue to become infected the same line of treatment 
is instituted. Careful observation of hundreds of cases have demonstrated 
that patients who have received w r ater by the mouth immediately after vom- 
iting ceased, do not excrete any more urine than patients who had received 
a thorough preparation and who had been denied water for the first twenty- 
four hours. The average amount in both cases is one pint. If proctoclysis 
is utilized intermittently during the period in which water is prohibited by 



212 Water and Nourishment 

the mouth — the amount of urine is increased far above the normal. (See lec- 
ture on "Preparation of Patient for Operation/' section "Water," also 
lecture on "Transfusion — Infusion/' section "Proctoclysis.") 

The appropriate length of time to maintain gastro-intestinal rest, in other 
words, the period in which nothing should be given by the mouth, depends 
on the conditions zvhich have been encountered zuithin the abdominal cavity 
and the general constitutional symptoms which are manifested for the first 
day or two after operative interference. The rule being, the more severe 
the infection, the longer should be the period of total abstinence from liquids 
by the mouth, and vice versa, in uncomplicated and noninfected cases the 
time limit is shortened. 

Thus if during an operation a local infection is encountered, or a tendency 
to a general peritonitis observed, fluids by the usual channel are denied the 
patient for forty-eight hours and occasionally three days, depending upon 
the constitutional signs which develop. During this period, intermittent 
proctoclysis is administered. Then water and liquid nourishment are given 
for three days, beginning with an ounce hourly, and gradually increasing the 
amount until at the end of the second day the patient is getting all the fluids 
desired. 

If no unfavorable symptoms are noted when fluids are first administered 
the indications are that Nature has been able to cope with the infection. A 
soft diet is now substituted for about three days ; at the expiration of this 
time regular meals may be given, which as a rule will be about the eighth 
or ninth day. 

If when fluids are first administered there is observed an increased 
distention of the abdomen, pain, eructations of gas, and possibly vom- 
iting, accompanied with an increased pulse and elevated temperature, 
all liquids by the mouth are stopped for twenty-four hours and rectal in- 
fusion again utilized. These signs are prima facie evidence that the 
increased peristalsis caused by the liquid nourishment is disseminating the 
infection within the peritoneal cavity, and Nature has been unable to over- 
come it (or in exceptional cases some obstruction of the bowel may be 
present), so that it would be extremely injudicious to continue giving fluids 
to further extend the infection. After a period of twenty-four hours liquids 
may be again resorted to in the same gradual manner as described above, 
for three or four days, followed by a soft diet, until at the end of the tenth 
or eleventh day a regular dietary is being administered. 

In uncomplicated and non-infected cases, the same line of treatment is 
carried out, the only difference being the period of gastro-intestinal rest is 
shortened twenty-four hours. Soft diet may be resorted to earlier and the 
regular dietary resumed at the end of a week. There is no question that 



Diet List 213 

liquid nourishment induces abdominal distention, consequently a soft diet 
should be resorted to as soon as expedient. 

No fixed rule can be given as to when liquids may give place to a soft 
diet, or this latter be replaced by regular meals. Each individual case is 
a rule unto itself. The point to be emphasized is, the greater the degree 
of infection encountered, the longer should be the period of g astro -intestinal 
rest, and the manner in which the patient receives the first administration 
of fluids is the indication as to whether further rest is necessary or not. 

During the period in which g astro-intestinal rest is maintained by pro- 
hibiting -fluids of any kind by the mouth, water is administered by Murphy's 
system of proctoclysis. In this way large volumes are absorbed, the system 
Hushed, and the kidneys {the great excretory organs of the body) stimulated 
to their full capacity. (See lecture on ''Transfusion — Infusion," section 
"Proctoclysis.") 

In operations on the vagina and rectum (where it is desired to afford the 
latter organ rest for several days after surgical interference), and the dif- 
ferent forms of hernia (where the effort to evacuate the bowel may prove 
disastrous to the results of the operation), a liquid diet is maintained for 
six or seven days so as to leave as little residue in the bowel as possible, after 
which a soft diet is given for three or four days, followed by a regular 
menu. 

In cranial operations a liquid diet is maintained for a like period. 

In operations in other regions the liquid nourishment is maintained for 
twenty-four or forty-eight hours, followed by a soft diet for three or four 
days, at the end of which period a regular regime is established. 

Diet List. — I have been surprised at the diversity of opinion among 
nurses in hospitals and private practice as to what articles they consider 
constitute a liquid diet, and what foods are placed in the soft-diet list. I 
cannot conceive why lamb chops and chicken should be placed in this latter 
menu, and yet in several instances these are given under this bead. The 
fact is, the average surgeon has no idea when ordering a "soft diet" what his 
patient actually receives. I am satisfied if he knew such meats as I have 
mentioned were included he would be horrified. It is only another example 
of errors creeping in the routine of hospitals and private practice, unless the 
strictest supervision is maintained. The chief of staff of any hospital, 
especially those having a training school for nurses, has no sinecural task, 
the details of which all tend toward a high standard of education. A nurse 
who is allowed to give chicken and lamb chops as articles of soft diet in her 
training-school course, follows the same regime in private practice. If she 



214 Diet List 

becomes a head nurse of another hospital the same error is disseminated in 
that institution, and so on ad infinitum. 

Uncooked egg albumen should form one of the chief ingredients in a liquid 
diet. It is easily digested, and being tasteless the patient does not tire of it. 
It can be made to form an ingredient in so many drinks that it certainly 
should hold an important place in this class of food. In my lecture on the 
"Preparation of the Patient for Operation," when speaking of the prepara- 
tory diet, I mentioned that if a stated amount of egg albumen were placed in 
the different broths a nutritive value would be given them, which otherwise 
are useless from the standpoint of nutrition. I also referred to the best 
way of preparing this substance. It may be added to lemonade, orangeade, 
and other fruit juices with water, frozen or otherwise. It is a common thing 
to witness nurses giving patients albumen lemonade day after day; instead 
of changing the flavor of the drink, they seem to forget that the taste needs 
diversity to tempt the appetite. 

The diet list as used at Dr. Howard Kelly's private sanatorium certainly is 
the best that has come under my observation. With his permission I ap- 
pend it — 

Liquid Food: 

Milk — Plain, peptonized, malted; with albumen, with fruit juices, and 
koumiss. Buttermilk is one of the best articles in the dietary. 

Wines — Grape juice (unfermented), wine whey, and in exceptional cases, 
a little whiskey if the patient is not doing well. 

Broths — Beef tea, beef broth, broiled beef juice, chicken broth, oyster 
broth, clam broth, somatose. 

Soups — Mock bisque, tomato, cream of rice, cream of asparagus, cream 
of pea, consomme, bouillon, and chicken soup with rice. 

Soft Food: 

Eggs — Poached, shirred, and soft-boiled. 

Jellies — Wine, orange, or coffee jelly. 

Creams — Apple float; whipped, orange or Spanish cream; cream of 
tapioca, cream of rice, baked custards in cups, boiled custard with float, 
tapioca with baked apples, arrowroot blancmange, orange sherbet, lemon 
sherbet, junket (plain or made with wine) panade. 

Special Diets: 

Oysters and Sweetbreads — Creamed oysters, broiled oysters, oysters on 
the half shell, creamed sweetbreads, broiled sweetbreads. 
Eggs — Poached, shirred, and soft boiled. 
Beef — Scraped beef sandwiches. 



Nutrient Enemata 215 

Birds — Partridges (broiled or roasted), broiled squab, chicken stewed 
with rice. 

Porridge — Wheat flakes, oatmeal (strained), and other cereals, such as 
cream of wheat. 

I cannot however agree to the use of milk immediately before and after 
abdominal operations because it is seldom thoroughly digested, as the com- 
mon occurrence of curds in the stools demonstrate. The undigested particles 
form most excellent culture-media for the colon bacillus, and hence it is 
one of the greatest factors in the production of flatus, which is the sur- 
geon's bete noire during manipulations in the abdomen, and after surgical 
interference it adds great discomfort to the patient. On the other hand 
when the abdominal cavity is not the field for operative attack, if the diges- 
tive system is in a normal condition milk is an excellent article in the dietary 
of the patient. Its diuretic qualities are not to be underestimated, while the 
many ways it can be utilized render it a factor in feeding the surgically 
sick. However, five or six days after celiotomies when flatus and its accom- 
panying distention have ceased to irritate the patient, milk and its different 
preparations may be administered. 

Nutrient Enemata — Rectal Feeding. — The practice of feeding patients 
by way of the rectum dates back to the earliest times in medicine ; the 
ancients seem to have recognized the necessity for gastro-intestinal rest. The 
two questions that have always been uppermost in the mind of the physician 
are: 

(1) Is the rectum capable of sufficient absorption to maintain the econ- 
omy's equilibrium for a limited period? 

(2) What articles of nutrition are best absorbed by the rectum? 

For years it has been taught that albumen in its many forms was one of 
the easiest substances absorbed by the lower bowel, and for this reason it 
should be the chief ingredient in all rectal feeding; that fats were very dif- 
ficult of absorption, and hence should be omitted in nutrient enemata ; so that, 
even in books published within the past year, the yolks of eggs which con- 
tain a large amount of fats were considered inappropriate as an article of 
dietary when the rectum was to be used as the avenue through which 
nutrition was to be supplied. 

In the numerous formulae for rectal feeding which I have found in hos- 
pitals and books, few if any mention carbohydrates. More attention has 
been given to this form of feeding in the last few years than formerly, 
principally because of the necessity for rest in our modern methods of treat- 



216 Nutrient Enemata 

ing gastric ulcers, etc. Scientific investigations have demonstrated the 
following conclusions : 

(1) That albumen is poorly absorbed in the rectum even when pre- 
digested. 

(2) The addition of salt assists to some extent the absorption of albumen. 

(3) The absorption of fats is greater than was formerly supposed, al- 
though the capacity for absorption varies in individuals. It is best adminis- 
tered in an emulsified form or in the natural condition as found in the yolks 
of eggs. 

(4) The use of sugar (carbohydrates) is recommended^ the absorption 
of which seems to vary with the capacity of the individual. 

(5) The rectum is capable of affording about one-quarter of the nourish- 
ment required to maintain the economy's equilibrium under the best con- 
ditions. The amount given at each feeding should be from eight to ten 
ounces, which is preferable to the smaller amounts (four to six ounces) 
formerly used, for the following reasons : 

(a) Longer intervals between injections affording rectal rest. 

(b) A larger water absorption. 

(c) A longer period of gastric rest, for it must be remembered when 

nutrient enemata arc introduced into the rectum they excite gas- 
trie secretion. 

The following formulae may be used : 

No. 1. 

Yolks of two eggs. 

Pure dextrose (grape sugar) q, 1 

Common salt grs. 8 

Pancreatized milk 5 10 

Mix. Inject into the rectum slowly. — Drs. F. D. Boyd and J. Robertson. 

As a substitute for the milk in the above formula, I prefer — 

Liquid peptonoids § 2 

Normal saline solution 5 10 

No. 2. 

One whole egg. 

Chlorid of sodium grs. 15 

Peptonized milk ^ 10 



Brandy or whiskey § 



T 2 



Mix. Inject slowly. — Mrs. Harriet Fenzel, Superintendent of Nurses, 
Protestant Hospital. 



Catheterization 217 

All enemata are administered at a temperature of 110°F. and will be 
about body-heat when received in the bowel. Alcoholic stimulants may be 
added to any formula when considered necessary. 

The Administration of Nutrient Enemata. — One of the most frequent 
duties in which a nurse fails to accomplish the desired end is the adminis- 
tration of nutrition by way of the rectum. This is because of two factors — 

(1) The nutritive material as a rule is not bland, but frequently irritat- 
ing, and especially is this true when alcoholic stimulants are added. 

(2) The nurse is unacquainted with the physiologic principles and the 
law of physics which govern the administration of fluids by this avenue, the 
details of zvhich have been set forth in the lecture on "Transfusion — Infu- 
sion," section "Proctoclysis." 

Nurse's Duties. — 

(1) Cleanse the rectum of all fecal material by the injection of warm 
saline solution. 

(2) Prepare a reservoir as for proctoclysis and equipped in a similar 
manner. 

(3) Place the nutrient mixture in the reservoir at a temperature of 
110°F. and maintain it at that point. 

(4) Lubricate the rectal nozzle with vaselin, never with glycerin, as it 
causes an expulsive effort on the part of the rectum. Suspend the reservoir 
from four to six inches above the plane of the rectum. Insert the nozzle 
after allowing all air to be expelled by the fluid. 

Under no circumstances should a hard-rubber piston syringe be used, nor 
a reservoir suspended at a height greater than six inches ; in many cases it 
should be less, because the force exercised in both cases excites bowel 
spasm. I am indebted to my friend Doctor John Dudley Dunham for call- 
ing my attention to an article written by Drs. Francis B. Boyd and Jean 
Robertson of Edinburgh, Scotland, on the subject of "Rectal Alimentation"; 
also an essay written on the same subject and delivered before the Ohio 
State Medical Society by him. From these two articles the foregoing de- 
ductions have been made. 

Bladder — Catheterization — Urine. — After some surgical operations it is 
necessary to catheterize the patient, as in operations on the female genitalia, 
such as the repair of the perineum, where a dry field is necessary to obtain 
the best results from the plastic work which has been performed. In such 
cases catheterization is resorted to every eight hours for four or five days. 
In other instances, either through a reflex action as in operations on the 
rectum, or from a paresis (partial paralysis) of the muscular walls of the 
bladder due to manipulations within the abdominal cavity such as the separa- 



218 



Catheterization 



tion of adhesions between the urinary viscus and other organs, the bladder 
is unable to empty itself and catheterization is resorted to until the muscles 
have regained their normal tone. 

This artificial means of emptying the bladder is by no means void of com- 
plications : I can think of no other procedure which is more liable to 
produce infection. Many patients leave our hospitals cured of the ailment 
for which they were operated on, but having a legacy in the form of a 
cystitis which in many instances causes as much distress as their primary 
disease. Cystitis as the result of catheterization in the large majority of 
cases is due to carelessness on the part of the nurse, — slovenly technic, 
which is as reprehensible as any one error a nurse can commit. 




Illustration LIV 
Self-retaining- Catheters. — The so-called " mushroom tip 



Before catheterization is attempted the parts around the urethra should 
be thoroughly cleansed with a warm saturated solution of boracic acid, or 
what I prefer, a solution of biniodid of mercury 1 :5000. This variety of 
mercury is preferable to the corrosive sublimate, being non-irritating and five 
times as germicidal. The surrounding area should be protected by sterile 
towels, the catheter boiled and lubricated with some aseptic demulcent, the 
nurse's hands cleansed, and sterile gloves used. 

Catheterization should be resorted to as seldom as possible. In those 
cases in which the bladder refuses to empty itself, whether from a reflex 
spasm, or a paresis the result of operative interference, it is frequently good 
policy after the bladder is emptied to allow the catheter to remain in place 
and repeatedly fill and empty the viscus with hot boracic-acid solution. The 
walls of the bladder in this way are stimulated to contraction, besides which 
the slightly antiseptic solution cleanses this portion of the urinary tract. If 



Urine — Bowels — Cathartics 219 

the condition of the patient warrants, the internal administration of some 
diuretic will be ordered by the surgeon. 

It is frequently necessary to leave a catheter in the urethra following 
operations on this canal, bladder, or prostate, to act both as a drain and as a 
means through which to irrigate. This form of catheter is so constructed 
as to mechanically retain itself in position, hence it is known as a retention, 
or self -retaining catheter. (See illustration LIV.) 

Urine. — It should be a rule to send a specimen of urine to the clinical lab- 
oratory on the third or fourth day after all operations, and sooner if there 
exists a deficiency in the amount of urinary excretion. The report of the 
same is annexed to the chart. This is especially necessary in cases which 
have been operated on for an acute infection. The functionating capacity 
of the kidneys at all times is one of the conservation processes of the 
economy, and especially is this true following surgical procedures. The sur- 
geon should therefore know if the work of these important organs is being 
carried out during this period. Negligence along this line has been the 
cause of deaths. The daily memoranda probably indicate the deficiency of 
urinary excretion, but no notice is taken of the same until complete sup- 
pression occurs ; then active steps are taken to rectify this oversight. It is 
just as essential to examine a patient's urine after an operation as before. 
Again, if a summary is kept on the memoranda-sheet of the total amount of 
urine excreted per day it indicates instantly the amount of work accom- 
plished by these important organs. (See lecture on "Ward Service," section 
"Clinical Charts and Sickroom Memoranda.") 

Bowels — Cathartics. — At the present time laxatives are not given the day 
following abdominal operations as was formerly the custom, but a mild 
cathartic is generally administered about the third or fourth day, providing 
the bowels have not acted of their own accord. In other words, this step 
is taken after the effects produced by a liquid nourishment on the patient 
are known, and before a soft diet is begun. Calomel is generally employed, 
usually gr. 1/4 for six or eight doses, to be followed the next morning with 
a tumbler of solution of citrate of magnesia. If after a few hours following 
the administration of the saline no evacuations have occurred, a soapsuds 
enema is usually ordered. Should this produce negative results, the sur- 
geon will possibly wait until the following day and repeat the cathartic. 
The frequent repetition of enemata alarms patients, through fear of some 
intestinal obstruction, besides which there is certainly no immediate neces- 
sity to evacuate the bowel — in fact the use of cathartics following abdominal 
operations has been abused. 

In operations on the cranium laxatives are begun about the second or 
third day, the same cathartic utilized as for celiotomies. Enemata are espe- 



220 Operative Wound — Dressings 

cially indicated to mechanically soften the first stool and assist in an easy 
evacuation. I mention this advisedly, as in a cranial operation occurring 
in my practice where great effort in straining was made, venous oozing oc- 
curred sufficient to moisten the dressings. 

It is certainly conservative to prevent an evacuation of the bowel for at 
least four or five days following operations on the vagina (such as the repair 
of the perineum), or in operations on the rectum (as in cases of fistulae) 
where the sphincter ani has been severed. There is a great diversity of 
opinion among authorities as to the proper time for the administration of 
cathartics under such circumstances, some advising their use twenty-four 
hours after the operation, while others desire ten days to elapse. As a rule 
the salines are chosen because of the thin watery stool they produce. Imme- 
diately before the cathartic is about to act an enema of soapsuds is admin- 
istered which is retained as long as possible to soften any hard fecal mass 
that may be present. The patient should be admonished that no extra exer- 
tion at straining should be made. 

In surgical interference in other portions of the body these remedies are 
administered according to the exigencies of the case. After emergency 
operations (excepting in accidents within the abdomen when intestinal rest 
is necessary) the surgeon probably will order a cathartic as soon as pos- 
sible because the patient has received no preparatory treatment. The in- 
testinal tract is foul ; the circulation is in consequence impeded, and the 
functions of the economy cannot be carried on to a normal standard. Fre- 
quently, a brisk cathartic will also stimulate a free urinary excretion. 

Operative Wound, Dressings, and Sutures. — A clean wound which has 
been aseptically dressed and without drainage as a rule requires no atten- 
tion. The generous amount of primary dressings necessary to absorb any 
oozing which may occur for the first day or two, and to serve as a soft 
cushion for the newly cut part ; or, as in abdominal operations, to lessen the 
jar and support the abdominal wall during the stage of vomiting, the sur- 
geon will order changed for lighter dressings possibly at the end of the 
first week. If however, drainage was used, your orders in all probability 
will be to remove the same within twenty-four or forty-eight hours. In 
abdominal operations the heavy scultetus bandage if it has been employed 
should be laid aside at the end of a week; six- or eight-ply gauze (12 by 12) 
held in place by strips of adhesive plaster are more comfortable. 

If toward the latter part of the first week there is an increase of pulse 
and temperature the wound should be inspected. If infection is found to 
be present such sutures will be ordered removed as afford the best drainage, 
at the same time bridges of adhesive plaster are used to prevent excessive 



Equipment — Steps of Technic 221 

gaping of the incision. From this time on the wound will be treated as an 
infected one. (See lecture on "Wounds.") 

Sutures. — If no infection has occurred in the wound the sutures are al- 
lowed to remain in place until the eighth or tenth day when they are removed 
in the manner already described in the lecture on "Wounds." I shall again 
repeat the details because of the careless manner in which this procedure is 
so frequently performed — 

Necessary Equipment. — ■ 

(1) 1 pair of sharp-pointed scissors and dissecting forceps (sterilized). 

(2) Sterile glass of hydrogen dioxid. 

(3) Alcohol or Harrington's solution. 

(4) Sterile towels. 

(5) Dressings. 

(6) Wipe sponges. 

(7) Gloves. 

(8) Adhesive plaster. 
Steps of Technic. — 

(1) Remove bandage and dressings, excepting the gauze adherent to the 
wound. 

(2) Cleanse hands. 

(3) Adjust sterile towels around field to prevent contamination from 
clothing. 

(4) Adjust dry sterile gloves. 

(5) Moisten the gauze adherent to the wound with hydrogen dioxid 
until the crusts are thoroughly softened, and the gauze is loosened from the 
wound — no traction is permissible to remove the same. 

(6) Saturate a piece of gauze with alcohol or Harrington's solution and 
lay over the stitches for one or two minutes. 

(7) With the aid of dissecting forceps pull one side of the stitch upward, 
cut the same as close to the skin as possible, then remove the suture. 

(8) Apply sterile gauze dressings, held in place with adhesive straps, to 
protect the stitch holes. 

Patient's Toliet. — The gown the patient wore during the operation was 
removed in the surgery and a clean one substituted, so that it seldom will 
be necessary to pay any attention to this part of the toilet for the first 
twenty-four hours and possibly two days, depending on the physical condi- 
tion of the patient, but it should be protected by towels draped over the 



222 Abdominal Operations 

chest and around the neck of the patient in case vomiting ensues. The 
gown is changed every other day thereafter. 

Tepid sponge baths (105° to 110°F.) are given about the third day, pro- 
viding the case is progressing favorably, otherwise these baths will be post- 
poned for a day or two. The use of alcohol rubs at night are in order 
after the first twenty-four hours. The hair is combed and braided. The 
finger nails manicured, and the teeth cleansed. In short, the patient's toilet 
should be as esthetic as the physical condition will permit. The bed linen 
should be changed every other day, unless existing conditions indicate other- 
wise. In these various steps looking toward the comfort of the patient, care 
should be exercised to prevent any unnecessary fatigue for the first few 
days after an operation. I have frequently seen the clumsy manipulations 
of a nurse so thoroughly exhaust patients that they would rather be left 
alone than submit to a fresh toilet, which under proper conditions should 
be a pleasure. 

Period of Confinement to Bed. — There is no standard rule governing the 
length of time necessary for the patient to remain in bed after an operation. 
This of course varies with the nature of the surgical procedure, and the 
individual views of the surgeon. But this axiom should be borne in mind, 
after convalescence is established, sunlight, fresh air, and exercise are more 
conducive to a normal restoration of health than prolonged confinement in 
bed. The average patient suffers more or less from psychic impressions, 
the result of the operation, — they are nervous. The operation becomes an 
epoch in his or her life, and everything from then on is dated from that 
time. The hospital and surroundings serve to prolong these impressions, so 
that the term of hospital confinement should be as limited as the nature of 
the case will permit. 

Abdominal Operations. — About the tenth day in favorable cases the sur- 
geon will probably allow the patient to recline on a back-rest, with an> ad- 
monition not to overtax the strength to the point of fatigue. Two days later 
the patient will be permitted to sit in a chair at intervals for a similar period. 
It is the nurse's duty to assist in these preliminary steps, and not permit 
any extra exertion on the part of the patient. About the fourteenth day the 
patient is allowed to walk around the room, and in a few days to return 
home. 

In cases in which complications have occurred you can easily appreciate 
no definite time can be assigned for the patient to remain in bed. 

Following celiotomies, it is the custom among some surgeons to have a 
semielastic abdominal supporter adjusted to the patient before they are per- 
mitted to walk, and which they are advised to use for two or three months. 
Personally I concur in the advisability of an abdominal supporter in all 



Other Operations 223 

cases, especially in obese patients with pendulous abdomens, whose ab- 
dominal walls are so weakened as to be considered nil. In any case the arti- 
ficial support lessens the numerous jars which are severely felt in walking 
after abdominal operations, and I think it adds comfort to patients and gives 
them confidence in themselves ; but I do not advise this support as a means 
of preventing a hernia occurring in the abdominal incision. If a proper 
technic is used in closing the wound and it heals by first intention, no hernia 
will develop ; if infection occurs or the incision has been poorly coaptated, 
nothing will prevent a rupture. 

• After operations for inguinal or femoral hernia the patient should be kept 
in bed for three weeks providing no complications occur. This is necessi- 
tated on anatomical grounds. 

Operations in Other Regions. — It is impossible to definitely give the time 
limit for a patient to remain in the recumbent position for the various opera- 
tions occurring in the different regions of the body, but the same general 
principles are observed as have been given in abdominal operations. The 
strong, healthy, robust workman, or those of advanced age, Avho because of 
some accident or acute infection are forced to submit to an operation, will 
feel the effects of confinement quicker than the chronic invalid. Realizing 
this, the surgeon shortens the period of confinement to bed consistent with 
convalescence. 

BIBLIOGRAPHY. 
Operative Gynecology— H. A. Kelly, A. B., M. D., LL. D. 



LECTURE XXIII 



SOME POSTOPERATIVE COMPLICATIONS 



Surgical procedures are occasionally followed by complications which not 
only influence the immediate results of an operation but frequently leave 
their impressions indefinitely on the patient. Among such complications 
may be mentioned — 

(1) Shock. 

(2) Hemorrhage. 

(3) Tympanites. 

(4) Infection of operative wound. 

(5) Peritonitis. 

(6) Nephritis. 

(7) Phlebitis. 

(8) Thrombosis. 

(9) Embolism. 

(10) Septic intoxication. 

(11) Septicemia. 

(12) Pyemia. 

(13) Pneumonia. 

(14) Acute obstruction of the bowel. 

(15) External fecal fistula. 

(16) Erysipelas. 

(17) Tetanus. 

It must be distinctly understood that while these subjects are mentioned 
in this connection, they are by no means limited to this period, but fre- 
quently occur independent of operative procedures. The importance of 
Shock, Hemorrhage, and Nephritis, and their association with other surgical 
conditions, made it necessary to consider them in my earlier lectures. 

Tympanites. — By this term is meant, the distention of the abdomen due to 
an abnormal amount of gas within the intestine. This condition is a fre- 
quent complication following abdominal operations. It varies in severity 

(224) 



Tympanites — Causes — Treatment 225 

from the simple type in which colicky pains are experienced and slight dis« 
tention is noticed, to one in which the distention assumes enormous propor- 
tions and causes pressure on the thoracic organs as manifested by a rapid 
pulse and shallow and increased respiration. 

Causes. — 

(1) A paresis or partial paralysis of the intestine, superinduced by 
manipulations within the abdomen such as the handling of the viscera. 

(2) Prolonged pressure from abdominal sponges, producing a similar 
paresis. 

(3) A reflex condition caused by surgical operations on certain organs 
within the abdomen and pelvis. 

(4) Excessive catharsis in the preparatory treatment. 

(5) The psychic effect of an abdominal operation on highly neurotic pa- 
tients, especially in those who have previously undergone a celiotomy. 

(6) A strictly liquid diet undoubtedly increases the distention. 

Symptoms. — Usually between the second and third day after an ab- 
dominal operation the patient complains of severe colicky pains through 
the abdomen, with possibly an inability to evacuate gas per rectum. The 
temperature and pulse at first are not increased. Vomiting is absent in 
a large majority of cases. The facial expression is normal. In rare in- 
stances distention becomes so marked as to seriously interfere with breath- 
ing and the action of the heart. The respirations are rapid and shallow, the 
pulse and temperature increased, and a facial anxiety developed. Vomiting 
is then not uncommon. 

Treatment. — In ordinary forms of this complication a rectal enema similar 
to one of the following formulae should be administered by means of a colon 
tube introduced as far into the bowel as possible. 

Epsom Salts q. 2 

Glycerin § 4 

Turpentine 3 1 

Water q. s pt. 1 

Mix. Sig. Use as directed and repeat if necessary in two or three hours. 

Milk of asafetida 5 4 

Turpentine 3 1 

Rich soapsuds q. s pt. 1 

Mix. Sig. Administer in same manner, and repeat if necessary. 



226 Infection of Operative Wound. 

In the exceptional cases of enormous distention the rectal catheter should 
be introduced as high in the bowel as possible and allowed to remain in 
position. This is best accomplished by the nurse inserting her finger in the 
rectum as a guide to the instrument. To facilitate this procedure some 
authorities advise the knee-chest posture, but this latter step would hardly 
be justifiable excepting possibly in the most severe forms of this trouble 
because of the short interval which has elapsed since the operation. 

Locally hot turpentine stupes, consisting of several layers of flannel wrung 
out of the following mixture and placed on the abdomen, are ordered: 
Turpentine 1 ounce, hot water 4 pints. These layers of flannel should then 
be covered with rubber sheeting over which is placed several folds of dry 
flannel. These applications should be kept warm by frequent changes. 

Internally the surgeon will order some brisk cathartic. 

For years I have used the following combination hypodermatically with 
excellent results : 

Eserin salicylate gr. 1/40 

Strychnin sulph gr. 1/30 

All food should be stopped ; its presence in the alimentary canal does no 
good, but possibly harm by increasing the formation of gas and exciting 
vomiting. 

Nurse's Duties. — 

(1) Stop all nourishment and the administration of water immediately. 
By this means you will be acting conservatively until you ascertain the sur- 
geon's views. 

(2) Report to the surgeon or proper authority that distention of the 
abdomen is occurring; whether pain is present, its character and severity; 
the pulse rate ; degree of temperature ; facial expression, and the presence 
or absence of vomiting. The surgeon should be made cognizant of all details, 
especially in cases where severe infection has been encountered, or dense 
adhesions have been separated, because he is the only one in a position to 
judge whether the tympanites is due merely to a temporary paresis, or if 
there is a probability of peritonitis ensuing, or an obstruction of the bowel 
developing. 

Infection of Operative Wound. — This complication generally occurs 
about the end of the first week after operative interference. 

Symptoms. — A slight elevation of temperature will be noticed, possibly 
chilly sensations, and a complaint of pain in the wound ; or at times these 



General Remarks on Peritoneum 227 

symptoms will be absent and the infection remain unnoticed until the first 
dressings are removed. 

Causes. — 

(1) Improperly prepared field of operation. 

(2) Lack of care in the protection of the field during the operative 
procedures. 

(3) Mangling of the tissues by carelessly applied hemostats, or bruising 
the edges of the wound by too forcible application of the retractors. 

(4) Debris left in the wound, such as blood-clots and devitalized tissue. 

(5) Excessive tension of the coaptating sutures, in this way interfering 
with the circulation. 

(6) The penetration of the staphylococcus which inhabits the superficial 
layers of the skin to the deeper subcutaneous tissues by way of the suture 
hole. 

Infection of the operative wound is a complication every surgeon regrets, 
because convalescence is prolonged and scar tissue is increased. In ab- 
dominal cases the process of suppuration may extend to such a depth as to 
weaken the underlying structures and thus cause a hernia to form; or in 
operations for hernia the same complication may nullify the surgical pro- 
cedure. While in operations on the extremities the scar tissue left by the 
wound having become infected may entangle nerve filaments in its meshes 
and cause constant suffering, or the suppurative process may be so exten- 
sive as to necessitate reamputation. 

Occasionally the entire wound does not suppurate, but owing to some 
unabsorbed buried suture, or some diseased condition of the bone, or some 
infection at a remote point, the pus burrows from the deeper tissues and 
discharges externally through the wound. A channel or sinus is thus formed 
which is known as a suppurative sinus. 

Treatment. — This is the same as has been given for infected wounds in 
the lecture on that subject. 

Nurse's Duties. — These are also similar. 

General Remarks on the Peritoneum. — The peritoneum is a serous mem- 
brane which lines the abdominal cavity, and is reflected on the organs located 
within. Some of these are completely clothed by it, others partially. It 
can be easily understood that cavities, fossae, gutters, and grooves are 
formed during the process this membrane takes to cover the numerous or- 
gans, all of which have a bearing from a surgical standpoint. The surface 
measurement of the peritoneum is about equivalent to the area of the skin. 

It is very richly supplied with blood-vessels, probably more so than any 
other tissue in the body, these ranging in size from some of the largest in 



228 Peritonitis — Causes 

the economy to the smallest twigs that are found in the vascular system. 
This has an important bearing on the surgical mind. It signifies that Nature 
has endowed this thin, delicate membrane with facilities to protect itself, so 
that the peritoneum which was formerly considered exceedingly susceptible 
to infection is now known to possess the greatest resisting power of any 
tissue in the body, and fortunately it is so, for no tissue receives such abuses 
and insults as does the peritoneum. 

This serous tissue has several functions to perform. It absorbs and se- 
cretes fluids. By its smooth and moist surface it allows free movement of 
the numerous abdominal or pelvic viscera without friction. It possesses an 
inherent quality to adhere when two surfaces are brought in contact under 
pressure, or to form adhesions when inflamed. In this way repair of peri- 
toneal wounds are consummated and inflammatory conditions checked. It is 
this membrane which assists in the peritoneal-current I have so frequently 
mentioned. It is this tissue which drains the peritoneal cavity. Few 
lymphatics are found in the lower abdomen and pelvis as compared to the 
numerous absorbents which are encountered in the upper abdomen beneath 
the diaphragm, a fact of great importance from a practical standpoint. 

From this anatomical knowledge it can readily be appreciated why infec- 
tions occurring in the pelvis are not as serious as those developing in the 
higher zones of the abdomen, and the reason for the use of Fowler's position 
after all abdominal operations — because it affords postural drainage toward 
the pelvis, a harbor of comparative safety. 

Peritonitis. — This is an inflammation of the peritoneum. I shall not at- 
tempt to describe the various classifications which have been made, but will 
only speak of septic peritonitis. 

Causes. — This complication is always due to the presence of pathogenic 
bacteria. Their entrance into the peritoneal cavity may occur through 
various channels, among which may be mentioned — 

(1) An infection following appendicitis. 

(2) Ulceration of the gall-bladder, stomach, or intestines, accompanied 
with leakage into this serous cavity. 

(3) The rupture of a pus tube or pelvic abscess. 

(4) An infection from the uterine canal. 

(5) The final results of septicemia or pyemia. 

(6) Gangrene of the bowel from obstruction or embolus. 

(7) Any injury within the abdomen of sufficient severity to lower the 
resisting power of the part and permit of the propagation of pathogenic 
bacteria. 



Peritonitis — Symptoms 229 

(8) The introduction into the peritoneal cavity of microorganisms, the 
result of faulty technic, such as the use of non-sterile instruments, infectious 
sponges, or any break in the chain of asepsis. 

Symptoms. — The initial symptoms will depend on two of three factors — 
(1) The virulence of the pathogenic organisms or (2) the number of the 
invading bacteria, and (3) the amount of resisting power the economy can 
develop. 

If peritonitis develops from a sudden rupture of a gangrenous appendix, 
or the erosion of an ulcer through the intestines as in typhoid fever, or the 
bursting of an acute pus tube, or a leaking gall-bladder due to ulcerative 
processes occurring through its walls, the symptoms will be profound from 
the first. The devastation will be so great that Nature cannot muster her 
powers of resistance, but if such a pus tube ruptured during a surgical 
operation, or an intestine was injured sufficiently to spill its contents, or a 
similar accident happened to an appendix or gall-bladder, the precautions 
which were taken during the operation — such as the careful placing of 
sponges around the focus of infection to prevent soiling the peritoneum — 
would prevent to a very great exent the crushing down of the economy by 
the bacteria present in the infectious material. Nature would have an op- 
portunity under these conditions to develop a resistance against the invading 
infection, and hence the symptoms would not be as profound, but develop 
more gradually. This latter will be the condition met with in a large ma- 
jority of cases of peritonitis occurring after abdominal operations. 

Usually between the third and fourth day after a celiotomy distention of 
the abdomen will be noticed, which may at first be mistaken for ordinary 
tympanites. Sooner or later the patient complains of rigors, or possibly a 
decided chill followed by an increase of temperature, which varies decidedly 
in different cases. In some the mercury will reach 101°, while in others 
104° or 105°F. will be recorded. The pulse will vary in proportion to the 
temperature. The respirations increase; pain is present and is of a paroxys- 
mal character, subsiding at intervals only to return with great severity. 
Every movement of the patient aggravates this symptom ; examination of the 
abdomen, however carefully made, serves to increase the suffering. Vom- 
iting is an early symptom; at first, the contents of the stomach, which is fol- 
lowed by bilious emesis ; and retching, which accomplishes nothing excepting 
that it adds to the pain. Thirst now develops; the patient begs for water 
only to immediately vomit it. The respirations become more shallow as the 
pain increases, because an endeavor is made to prevent the diaphragm de- 
scending to such an extent as to produce undue pressure on the organs be- 
low. The position assumed in bed is characteristic, the legs are flexed on the 
thighs, the thighs partially so on the abdomen ; the patient demands more 



230 Peritonitis — Prophylaxis 

pillows placed under the shoulders to relieve the tension of the abdominal 
muscles, or lies on the side coiled in a position to accomplish the same object. 
Constipation is present. The urine is scanty. If the natural resisting forces 
of the body and the mechanical obstructions which Nature has thrown out 
in the way of adhesions, together with the assistance of such treatment as 
is instituted, are capable of overcoming the infection, these symptoms grad- 
ually subside. But if the case is progressive, the temperature climbs higher, 
the pulse becomes faster and more feeble, the respirations more shallow be- 
cause of increased pain and aggravated distention. Vomiting becomes 
incessant, which together with the great amount of toxemia present, only 
adds to the exhaustion and finally produces collapse. The facial expression 
during this progressive stage is one of grave anxiety ; the angles of the 
mouth are drawn, the nose is pinched, the eyes deep set, the skin assumes 
an ashy hue, while beads of perspiration moisten the entire surface, — the 
picture being complete of what is known as the "Hippocratic countenance," 
a symptom of impending dissolution. These are the common signs of a 
general septic peritonitis. There are wide variations from the above classic 
symptoms ; some so virulent from the very onset as to overwhelm the patient 
in twenty-four hours, while others run a course of a week or ten days with 
only a moderate elevation of temperature, and little or no distention or pain ; 
in fact, the classic symptoms are practically absent. Again occasionally the 
first sign noticed is a slight delirium occurring at night, generally at the time 
the usual symptoms first manifest themselves, that is about the third or 
fourth day, followed by the train of symptoms I have endeavored to depict. 

Prophylaxis (preventive treatment) is the ideal. It is our duty to carry 
out such details as will safeguard the patient from one of the most fatal 
diseases in abdominal surgery. This prophylaxis should include — 

(1) As thorough a preparation of the patient as time and the exigencies 
of the case will permit. 

(2) Constant care in the preparation and sterilization of such articles and 
instruments as are used during the operation. 

(3) The maintaining of a complete sterility during the operation, by dis- 
carding all instruments, sponges, etc., which have become infectious. 

(4) The judicious use of abdominal sponges around an infected area to 
prevent contamination of the general peritoneal cavity. 

(5) The wearing of such rubber gloves as are not damaged, however 
clean the hands are supposed to be. 

(6) The utilizing of the Fowler position from one to three days after all 
celiotomies and the employment of this same position before and during 
operative interference in fulminating cases. 

(7) The maintaining of gastro-intestinal rest. 



Peritonitis — Treatment 231 

In these preventive measures I have mentioned, some concern the nurse 
exclusively, others both surgeon and nurse. For instance, the preparation 
of the patient, the sterilization of sponges, instruments, dressings, etc., come 
within the province of the nurse ; while the position the patient assumes in 
bed after an operation, and whether or not gastro-intestinal rest is to be in- 
stituted, will depend upon the judgment of the surgeon. It is, however, 
quite proper for the' supervising nurse of the floor (in the absence of other 
authority) when a patient is admitted to the hospital suffering from some 
acute fulminating abdominal infection, to order such patient placed in the 
Fowler position immediately, and to withdraw all fluids and nourishment by 
the mouth until specific orders are obtained from the attending surgeon or 
proper authority. In this way she is safeguarding the interests of the pa- 
tient, and in no way trespassing on the prerogatives of the surgeon. In fact, 
there is as much justification in this procedure as there is for a nurse to 
control an emergency hemorrhage of an extremity by a tourniquet. 

Treatment. — This will of course depend on the origin of the infection. If 
the peritonitis is the result of a leaking appendix, perforation of a gastric 
ulcer, or ulceration of the intestine the result of typhoid fever, or from some 
accident which produces similar consequences, immediate operative inter- 
ference is indicated, looking toward the removal of the causative factor. 
Under such circumstances no extensive preparation is permissible. The 
after-treatment will consist of gastro-intestinal rest, the Fowler position, and 
proctoclysis. 

Septic peritonitis developing after a celiotomy is another problem. Some 
surgeons advise a generous cathartic of calomel and salines immediately the 
first signs develop. If in spite of this treatment the symptoms are pro- 
gressive these operators reopen the abdomen in an endeavor to discover the 
point of infection and cleanse it, thus reducing the base of supply. Another 
class of surgeons go a step further after carrying out the above technic and 
advise the irrigation of the abdominal cavity with large quantities of saline 
solution in the hopes of diminishing the amount of infectious material 
present. This is followed by free drainage. 

On the other hand, conservative surgeons oppose such radical technic. 
In their opinion rest is the sheet anchor from which to expect favor- 
able results. Cathartics are prohibited because by their use exaggerated 
peristalsis is developed, — a factor in the dissemination of infection. Their 
argument is : why should cathartics be used after operative interference 
when a septic peritonitis is developing, if the same is contraindicated as an 
ante operative measure in the presence of an acute local peritonitis through 
fear of disturbing adhesions and favoring the spread of infection? 

The reopening of the abdomen is censured on similar grounds. The 
breaking up of adhesions in an endeavor to locate the point of infection only 



232 Phlebitis — Thrombosis — Embolism 

serves to throw down the barricade which Nature has established to circum- 
scribe the infectious material, thus allowing fresh fields to become infected 
and permitting the inflammatory wave to extend unchecked. Furthermore, 
these operators argue, the depressing effects of the second anesthetic should 
be taken into consideration; that shock is invited by handling the intestines, 
especially in a patient whose resisting power is already below par ; that from 
an anatomical standpoint it is impossible to cleanse the abdomen, however 
thoroughly the work is done; that irrigation of the peritoneal cavity with a 
saline solution is only another means of disseminating infection, and that 
when all these facts are added together and statistics gathered of secondary 
operations for general septic peritonitis, the death rate, is increased, not 
diminished. 

These operators rely on postural drainage as obtained by the Fowler posi- 
tion ; gastro-intestinal rest to favor the formation of adhesions ; rectal feed- 
ing as a means of supplying nourishment; the Murphy proctoclysis as a car- 
diac stimulant, a diluent of toxic material within the circulation, and as a 
mechanical means to increase the urinary excretion, thus ridding the econ- 
omy of septic material (see lecture on "Transfusion — Infusion," section 
"Proctoclysis") ; morphin administered hypodermatically in the minimum 
dose to control pain and add further rest. Possibly hot turpentine stupes 
applied over the abdomen and frequently changed may be utilized (for the 
proper preparation of which see section "Tympanites" in this lecture). 

Phlebitis— Thrombosis — -Embolism. — Before taking up the discussion 
of these topics it may not be out of order to remind you that the inner coat of 
blood-vessels is clothed with a delicate lining composed of endothelial cells, 
the functions of which are the following: 

(1) To reduce to a minimum the amount of resistance caused by the 
blood-current through the vessels. In other words, it forms an antifriction 
surface. 

(2) To prevent the coagulation of the blood. 

(3) To aid in the process of repair of injured blood-vessels. (See lec- 
ture on "Blood-vessels," section "Histology.") 

With these facts in mind, I desire to call your attention to the more com- 
mon diseases occurring in the vascular system. 

Phlebitis. — By this term is understood an inflammation of a vein. This 
condition is occasionally seen after operations and produces a very unde- 
sirable complication. Its presence is practically always associated with a 
thrombus or clot in the vein, which is inflamed. Hence, the term thrombo- 
phlebitis conveys to the mind an inflammation of a vein in which a blood-clot 
has formed, partially or completely occluding the vessel. Phlebitis is a much 



Phlebitis — Results — Treatment 233 

more common disease than its relative acute arteritis, which is an inflamma- 
tion of an artery. 

Causes. — Phlebitis may be developed from the following factors : 

(1) The direct entrance of pathogenic bacteria through the walls of the 
vessel as the result of a local infection. 

(2) A general toxemia, the result of such diseases as scarlet fever, diph- 
theria, typhoid fever, pneumonia, rheumatism, and the different forms of 
septic infection such as septicemia, pyemia, etc. 

(3) Occasionally a phlebitis develops after an operation for which no 
cause can be assigned. 

Symptoms. — Pain and tenderness in the line of the vein; a mottled or 
marble-like appearance of the skin ; edematous swelling if an important vein 
is occluded, although this symptom is not always present. If the vein is 
superficial the course of the vessel can be distinctly felt, the feeling of which 
is tense and nodular. Should suppuration develop, in addition to these 
symptoms there will also be present those common to suppuration occurring 
in other tissues, viz., a sudden chill or occasional rigors, increased pulse rate 
and elevated temperature, loss of appetite, and digestive disturbances. 

Final Results. — In the early part of this lecture, I mentioned that one of 
the functions of the endothelial lining of the inner coat was to maintain the 
fluidity of the blood. If therefore as a result of a toxemia or the direct inva- 
sion of bacteria, a phlebitis is produced, the endothelial lining becomes so 
damaged as to destroy this function and permits the blood to become coagu- 
lated or clotted, — a thrombophlebitis is the result. If the inflammation of the 
vein has been produced by the invasion of pus-producing organisms, such 
as the streptococcus or staphylococcus, the tendency is for suppuration to 
occur in the vein and thrombus (clot). Should this be the result the infec- 
tious particles are carried by the blood-stream to remote parts (these frag- 
ments are termed emboli), become lodged and form nuclei for the develop- 
ment of abscesses. Even the mildest form of thrombophlebitis gives the 
surgeon great concern. The majority of cases occurring in the lower 
extremities subside in a few weeks under proper treatment, by a collateral 
circulation being established. In some instances, however, edematous swell- 
ing and pain continue for an indefinite period, during which time the patient 
is forced to use some artificial support to the circulation, such as band- 
ages, etc. 

Treatment. — This consists of rest general and local, varying from days to 
weeks, and sometimes months ; the application of cold or heat along the 
course of the vein during the acute stage ; the encircling of the limb if that 
is the part affected with a carefully applied flannel bandage; the elevation 



234 Thrombosis — Causes — Results 

of the limb to assist venous return of blood. Massage or rubbing of the 
limb is absolutely contraindicated. In this way the thrombus may be broken, 
the fragments float in the blood-current and thus become emboli, — a very 
dangerous complication. If suppurative phlebitis develops, the case becomes 
one for operative interference, and the vein is dissected. 

Constitutional treatment is directed toward the general condition of the 
patient and will be prescribed by the surgeon. 

Thrombosis. — By this term is understood the process by which the blood 
becomes clotted within a vessel or chamber of the heart. The clot or throm- 
bus as it is called remains at the site of origin and occludes the vessel par- 
tially or completely. 

Causes. — A thrombus or clot may form as the result of a phlebitis as has 
been explained. In fact I should say a phlebitis is the most prolific cause. 
The mechanical effects produced by wounds, contusions, and varicose veins 
on the inner coat of the vessels may develop thrombosis. Acute infections, 
as have been mentioned as a causative factor in phlebitis, are responsible for 
the development of a thrombus, because such infections not only produce 
changes in the walls of the vessels but bring about alterations in the char- 
acter of the blood. 

Classification. — A thrombus is classified as (1) simple or aseptic, (2) in- 
fectious or septic — depending as to its cause; if a clot forms in a blood- 
vessel as the result of a wound or contusion the thrombus would be classed 
as simple, but if following in the course of some acute infectious disease it 
would be considered of the infectious variety. 

Symptoms. — If the thrombus occurs in a superficial vessel and is asso- 
ciated with a phlebitis (which is true in a large majority of cases) the symp- 
toms partake of that disease. If an artery is occluded, pulsation is absent 
below the point of obstruction. A thrombus occurring in the mesenteric 
vessels produces all the symptoms of an obstructed bowel (q. v.), to which 
may be added the escape of blood from the rectum, — a very diagnostic symp- 
tom. The occlusion of a pulmonary vessel by a thrombus manifests similar 
symptoms as are seen in pulmonary embolism, although not as rapid in devel- 
opment, and will be considered under that head. 

Final Results. — // the thrombus is aseptic it may become organized 
and undergo the same changes as a clot that forms when a vessel is ligated^ 
which process I have described in the section of "Repair of Wounds of 
Blood-vessels." (q. v.) Gangrene of the part supplied by the occluded ves- 
sel will be the result if a collateral circulation cannot be established. If the 
thrombus be of the infectious variety suppuration is liable to occur, and 
fragments of the thrombus are carried to remote parts. These migratory 



Embolism — Causes — Symptoms 235 

fragments of the clot (emboli) may become the initial factors in the produc- 
tion of abscesses in remote organs and thus develop that condition known as 
pyemia. 

Treatment. — If the thrombus occurs in an extremity and is of the bland 
variety the same line of treatment is instituted as for phlebitis. A thrombus 
occurring in the mesenteric vessels demands a surgical operation because a 
collateral circulation cannot be established and gangrene will be the result. 
Infectious thrombi when accessible demand prompt surgical intervention. 

Embolism. — This term indicates the occluding of a vessel by a foreign 
body or embolus which has been brought from some remote part. Note the 
difference between an embolus and a thrombus. The latter is a stationary 
clot which remains at the site of formation, while the former is a migratory 
body floating in the blood-current, and eventually blocking a vessel. 

Causes of Emboli. — The majority of emboli are derived from fragments 
of a thrombus, or an entire thrombus dislodged and carried in the blood- 
stream to some remote part. There are other substances which may enter 
into the formation of these migratory bodies, such as detached portions from 
the wall of a diseased blood-vessel, or a ragged fragment of the inner coat 
which has become separated by being roughly clamped during operative 
measures ; particles of tumors which have eroded through the sides of ves- 
sels and thus entered the blood-stream ; deposits from a diseased valve of the 
heart ; fat globules ; clumps or masses of bacteria, etc. 

Classification. — The division made of thrombi is equally applicable to 
emboli, viz., (1) simple or aseptic, (2) infectious or septic, depending of 
course on the origin of the embolus. 

Symptoms. — The general picture is the same as in thrombosis, excepting 
the symptoms produced by an embolus appear more suddenly than those of 
a thrombus, because the circulation is interfered with immediately and not 
gradually. For this reason also an embolus is a more dangerous complica- 
tion than a thrombus, besides which, being a migratory body, it is liable to 
block the circulation of an important organ remote from its point of forma- 
tion. If an embolus originates from a suppurating thrombus or masses of 
pyogenic bacteria another picture may develop. These migratory bodies 
deposit their infectious material in remote organs, produce suppuration at 
these points, and lay the foundation for that form of general infection 
known as pyemia. 

The symptoms produced by an embolus when it blocks an important ves- 
sel of the lung, deserve special notice, because it is one of the causes of 
sudden death in postoperative cases, and frequently brings unjust criticism 
on both the surgeon and nurse. The symptoms are very profound, and 
appear without the slightest warning. A few hours previously, in fact a few 



236 Septic Intoxication — Septicemia — Pyemia 

minutes before the onset, every indication may point to a satisfactory con- 
dition. After some slight movement the patient complains of severe pain 
around the heart, followed immediately by a sense of suffocation; air hun- 
ger develops ; the face becomes ghastly and assumes an expression of anx- 
iety which of itself is characteristic ; the pulse which has been within normal 
range becomes faster and more feeble until it cannot be counted. Death 
may result instantaneously. Such a case occurred in a patient on whom I 
operated for the repair of the perineum. On the third day after the opera- 
tion when making my usual visits in the hospital her pulse and temperature 
were normal ; I assured her husband of her speedy recovery, and proceeded 
with my work. In a few minutes I was hastily summoned to the room, and 
was chagrined to see my patient dying. Another case which occurred in my 
practice followed a Cesarean section, the patient weighing 600 pounds. Her 
condition progressed normally until the eighth day, when in attempting to 
turn on her side to drink a glass of wine, she died suddenly, undoubtedly 
from a fat embolus. However, if only a small twig of a pulmonary vessel is 
occluded the symptoms will not be as severe. Difficult breathing, frequent 
coughing, and expectoration of blood are the signs usually present. 

Treatment. — This is the same as recommended for thrombosis. 

Septic Intoxication, Septicemia, and Pyemia. — As I have previously 
stated in one of my earlier lectures, infection is the successful entrance and 
multiplication of bacteria in the economy; that after such entrance has been 
accomplished these microorganisms eliminate toxins or poisons, capable of 
producing a similar infection to the bacteria from which they originated ; 
that the constitutional effects of the microorganisms and their toxins is 
termed toxemia or blood-poisoning, while by the term ptomain is understood 
an alkaloidal poison produced by putrefactive bacteria only. Also when 
speaking of the principles of infection I divided the subject into local and 
general. Local when a limited area alone is affected by the presence of bac- 
teria. General when "the entire blood-current is contaminated. I now desire 
to give you the three principal divisions of general infection, viz., (1) septic 
intoxication, (2) septicemia, and (3) pyemia. It must be clearly borne in 
mind while I have seen fit to place the different forms of general infection 
as postoperative complications, they are by no means limited to that period ; 
in fact, general infection probably follows in the wake of accidents oftener 
than as a sequence to operative measures. 

Septic Intoxication Incorrectly Termed Sapremia. — This is the general 
absorption of ptomains from putrefactive material, toxins from pyogenic 
bacteria, or both. You will notice in the definition given the microorganisms 
themselves are not absorbed, simply their chemical products. It was for- 
merly taught only ptomains from putrefaction were carried into the blood- 



Septic Intoxication — Symptoms — Treatment 237 

current; now it is conceded that the presence of toxins from the pyogenic 
organisms are frequently, if not constantly present. Putrefactive material 
which can produce septic intoxication is found in blood-clots which have 
become disorganized and retained in the uterus after labor, or in blood-clots 
and other fluids which have decomposed and become pocketed in a badly 
drained wound; in crushed and devitalized tissue left after surgical opera- 
tions without any means of escape; and in ruptured pus sacs within the 
abdominal cavity, even though no living microorganisms are present. 

The three essentials necessary therefore for the development of septic 
intoxication are : 

(1) Putrefactive material. 

(2) Pockets or cavities containing such material, without an exit. 

(3) Large absorbing surfaces. 

Symptoms. — The premonitory symptoms of septic intoxication are not 
distinct; I may say they are suggestive only, and consist of a dry tongue, 
headache, restlessness, high-colored and scanty urine, and a feeling of ill 
being. Sooner or later a severe chill, or chilly sensations are experienced, 
followed by a rapid rise in temperature which may reach 105 °F., accom- 
panied with a weak and fast pulse. My experience is the earlier the chill 
appears after an accident has been received, or surgical operation per- 
formed, the more suggestive is the case of septic intoxication. If the amount 
of putrefactive material absorbed is limited, or prompt drainage is imme- 
diately instituted, the symptoms subside in a day or two. In the severe 
forms where a large dose of ptomains or toxins have been absorbed the 
exhaustion from the beginning is pronounced, delirium is present, and the 
patient is overwhelmed with an aggravation of all the symptoms I have 
described. 

The Final Results. — These depend on the amount of toxins or ptomains 
absorbed and the facilities for drainage. While the large majority of cases 
recover under prompt treatment, occasionally the amount of absorption is so 
great as to overcome the patient's resisting power even though drainage has 
been instituted. 

Treatment. — All recesses and pockets should be carefully opened and 
drained so as to prevent any further absorption, and followed by thorough 
irrigations. Murphy's proctoclysis is the remedy to dilute the toxins and 
stimulate the function of the kidneys to the maximum. Purgatives of calo- 
mel are indicated. Alcoholic stimulants are administered. Highly nutri- 
tious liquid diet is given every three hours. Fever is reduced by tepid baths 



238 Septicemia — Symptoms 

and ice caps applied to the head and over the region of the heart. Hypo- 
dermatic medication of strychnin, digitalis, or camphorated oil is in order. 

Septicemia. — This is a general infection caused by the absorption of pyo- 
genic bacteria and their toxins, in contradistinction to septic intoxication, 
in which disease bacteria are not absorbed. Septic intoxication as I have 
already told you depends on the size of the dose of toxins absorbed, while in 
septicemia the primary dose of bacteria and their toxins may possibly be 
small, but the incessant multiplication of the absorbed bacteria increases the 
amount of toxins proportionately, so that the dose is becoming greater and 
greater. Again one of the essentials of septic intoxication is a large absorb- 
ing surface; while in septicemia a most insignificant wound, abrasion, or 
scratch may be the point of entrance of the bacteria. In septic intoxication 
after the cavity or pocket which contained the putrefactive material has been 
drained, absorption of the toxins or ptomains is immediately stopped and the 
economy has only to deal with the primary dose, but in septicemia, although 
the wound or abrasion through which the bacteria entered has been thor- 
oughly sterilized the limit of our efforts is reached, because the microorgan- 
isms have already invaded the general blood-current and the dose of infec- 
tion is constantly getting greater, unless the resisting powers of the body can 
overcome it. Therefore, in septic intoxication it is possible to mechanically 
stop absorption, in septicemia it is impossible. 

Symptoms. — The early signs are the same as in septic intoxication, only 
more aggravated. If a patient has undergone an operation or has been 
delivered of a child and there is not that return of well being which is de- 
sired; if there is prostration, headache, digestive disturbances such as a 
coated tongue, loss of appetite, and constipation, it is suggestive of an im- 
pending infection. If the patient has received some wound or abrasion, the 
same may be painful, with the local signs of an acute inflammation; red 
streaks may be observed coursing along the skin-surface, which are indica- 
tive of an inflammatory action in the lymphatic vessels (lymphangitis) ; in 
addition the constitutional symptoms spoken of develop. After four or five 
days the patient suffers a severe chill, or possibly rigors, followed by an 
increase in temperature which may reach 104° F. from the first, with a pro- 
portionate increase in pulse. The temperature having a tendency to rise in 
the evening and recede the following morning, so that the clinical chart 
shows an "up and down" curve of a degree or two. Occasionally the tem- 
perature may fall practically to the normal for a day, only to rise again to an 
alarming point, with a corresponding increase of pulse. Profuse sweats are 
common. If the resisting powers of the economy are sufficiently great to 
overcome the infection, a gradual restoration to the normal occurs. If on 
the other hand there is a continual multiplication of bacteria and their 



Pyemia — Causes — Symptoms 239 

toxins, the patient drifts into a state of exhaustion and the so-called 
''typhoid" symptoms appear. The tongue becomes dry, cracked, and bleed- 
ing; sordes collect on the lips and teeth; the breath is foul; the patient de- 
velops a low-muttering delirium, and picks at the bedclothing; involuntary 
diarrhea ensues ; the urine becomes less in amount and highly concentrated. 
Marked disintegrative changes occur in the blood. Inflammatory changes 
occur in the heart, lungs, liver, and kidneys. 

Treatment. — After the primary point of infection has been thoroughly 
cleansed and treated antiseptic ally the treatment will be the same as in septic 
intoxication ; in addition vaccines may be employed. 

Nurse's Duties. — Same as in "Erysipelas." (q. v.) 

Pyemia. — This is an acute general infection, having as its characteristics 
the formation of abscesses in portions of the body remote from the primary 
point of infection, and accompanied with irregular chills, fever of an inter- 
mittent type, and sweats. 

Causes. — When speaking on the subject of thrombosis I explained that 
when the thrombus was of the infectious variety and suppuration occurred 
in the clot the fragments became detached, floated in the blood-current, and 
were known as septic emboli. These infectious particles laden with bacteria 
and their toxins lodge in remote organs, and form the starting points for 
abscesses. Again, when speaking of the principles of infection, you were 
taught that bacteria could enter the circulation either through the medium of 
the lymphatics or by direct invasion of the capillaries. In either case after 
these microorganisms have gained entrance into the circulation, they are dis- 
seminated to various organs and become the starting points of abscess for- 
mation. Thus you can easily understand that during the course of sep- 
ticemia (in which bacteria are propagated within the blood-current), a 
pyemia can easily develop; because the microorganisms lodge in various 
tissues and organs and become the factors in the production of abscesses ; in 
fact septicemia is the most common cause for the development of pyemia. 

Symptoms. — The train of symptoms is not as rapid, nor do they appear 
as soon, as those of septicemia. The patient possibly has suffered for some 
time with thrombophlebitis, or some suppurative process, when suddenly a 
severe chill occurs, followed by a temperature which may rise to 104° or 
105 °F., with a corresponding pulse. These symptoms are succeeded by 
profuse sweats. The temperature recedes two or three degrees, and the 
patient feels somewhat improved. Suddenly another chill occurs, followed 
by a higher degree of fever and debilitating sweats. If the process of infec- 
tion continues, the chill which occurred every day or two may appear daily 
or two or three times a day, each time succeeded by a rise in temperature, 



240 Pneumonia — Treatment 

sweats, and finally a drop in temperature, so that there is a wide range in the 
excursions of the mercury. The chills are irregular, because there is no 
regularity in the formation of the different abscesses, nor in the elimination 
of the toxins. You can easily understand the profound impression which is 
being made on the economy. The amount of toxic material poured out 
through the kidneys is causing inflammatory changes to take place in these 
organs and impairing their function of elimination. Thus the toxic ele- 
ments are retained within the body, and only serve to break down the 
natural resisting powers. The appetite fails, making it necessary to force 
the patient to take nourishment. Diarrhea is present, and in protracted 
cases becomes involuntary. The various organs of the body undergo inflam- 
matory changes — especially is this true of the heart and its coverings. The 
effect on the brain and nervous system is manifested by muscular twitch- 
ings, picking at the bedclothes, and low-muttering delirium. Very few 
cases of true pyemia recover. 

Treatment. — All accessible abscesses are immediately opened and drained. 
Alcoholic stimulation and a highly nutritious liquid diet are administered. 
Murphy's proctoclysis, as in other general infections, becomes a sheet 
anchor. Heat is applied during the period of chills, tepid sponging when 
the temperature is excessive. Alcoholic baths are indicated to keep the 
mouths of the sweat glands free and assist the kidneys in their elimination. 
Vaccines are becoming more popular in the treatment of this disease. 

I have had several cases which undoubtedly owe their recovery to the 
administration of autogenous vaccines. (See lecture on "Surgery, Sur- 
gical Nursing, Infection," etc., section "Vaccines.") 

Nurse's Duties. — Same as in "Erysipelas." (q. v.) 

Pneumonia. — This complication may occur immediately after an opera- 
tion, or develop some days later. In the former case it is generally pro- 
duced by an excessive amount of anesthetic ; the use of dirty masks and 
inhalers ; undue exposure of the patient on the operating-table, especially 
when surrounded by wet clothing the result of the improper method of pre- 
paring the field of operation after the patient is on the operating-table. A 
pneumonia appearing some days after an operation, as a rule, develops from 
a septic process occurring elsewhere in the economy. Frequently the pul- 
monary complication is not recognized, and the aggravation of symptoms is 
attributed to the septic process from which the pneumonia developed. 

Treatment. — This is the same as for pneumonia occurring at other times, 
viz., the employment of the cotton jacket, plenty of fresh air, the minimum 
amount of anodynes to relieve local pain and control the cough, and the use 



Acute Obstruction of Bowel 241 

of stimulants ; especially are stimulants indicated in a pneumonia developing 
from some septic condition. 

Acute Obstruction of the Bowel. — I desire to consider only such 
obstructions as occur immediately after abdominal operations. 

Causes. — During the necessary manipulations within the abdomen which 
occur during a celiotomy the bowel may become twisted on its mesentery, or 
adhesions form between the intestines and some other organ, or between one 
portion of the intestine and another caused by the denudation of the peri- 
toneum. These adhesions cut off the peristaltic action of the intestine to 
the extent of obliterating the fecal current. A similar accident occurs when 
the muscular coat of the intestine has been damaged. Strangulation of the 
gut may occur, or at least peristalsis abolished by the intestine insinuating 
itself in a rent or tear of the omentum which was produced during operative 
procedures. To be concise, any acute mechanical cause which interferes 
with the fecal current will produce the symptoms of an obstruction. 

Symptoms. — The symptoms of an acute obstruction are very similar to 
those of acute peritonitis, in fact at times it is very difficult to diagnosticate 
between the two conditions. Severe colicky pains are usually the first mani- 
festations, subsiding at times only to recur. Tympanites makes its appear- 
ance as an early symptom. The character of this sign will depend upon the 
site of the obstruction. As a rule the surface of the abdomen has not the per- 
fect contour seen in peritonitis. One portion of the abdomen will be more 
distended than another so that an uneven appearance is observed. Vomiting 
soon develops ; at first the fluids of the stomach, later bile, and finally the 
bowel contents (stercoraceous vomiting). This symptom is incessant, and 
with the paroxysmal pains, soon exhausts the patient. Thirst is insatiable. 
The loss of animal fluids due to the vomiting produces a dry and parched 
tongue, and a diminution in the quantity of the urine excreted. If the ob- 
struction is complete there will be no escape of gas by the rectum; a small 
amount of fecal matter may occur after the use of enemata, which simply 
indicates the mechanical ejection of whatever residue there is in the lower 
bowel. The temperature and pulse at first are elevated ; the latter becomes 
more rapid, and the temperature drops below par in proportion to the ex- 
haustion of the patient. The Hippocratic expression soon develops. Pal- 
pation at times reveals a mass corresponding to the site of obstruction, but 
frequently the excessive tympanites and the severe pain which the patient 
suffers preclude a thorough examination by this means. 

Treatment. — The obstruction being mechanical can only be relieved by 
mechanical means, — surgical interference is indicated. Nourishment and 



242 External Fecal Fistula — Erysipelas 

fluids by the mouth should be withheld, as these only serve to increase the 
vomiting and exhaust the patient. Cathartics are absolutely contraindicated. 

Nurses Duties. — Before operative interference her duties will be similar 
to those given under "Tympanites" and "Peritonitis." After an operation 
has been decided on her duties will be the same as in any other abdominal 
operation, excepting that no preparatory treatment is given. If the first 
dressings have not been removed, the only cleansing necessary will be the 
use of tincture of iodin or Harrington's solution around the abdominal 
incision. 

External Fecal Fistula Following Celiotomies. — An external fecal 
fistula is the pathway by which the contents of the bowel escape through an 
artificial opening. The feces appear on some portion of the abdominal 
surface. 

Causes. — Mechanical injury to the intestine during an operation, as in 
separating adhesions, pressure from drainage tubes, abdominal and pelvic 
abscesses, defective intestinal suturing. 

Symptoms. — The first symptoms will be noticed about the second or third 
day after the operation ; occasionally a longer period will elapse before the 
first manifestations are noticed. Pain is complained of in the abdominal 
incision, and there is an increase of temperature and pulse rate. On in- 
spection the wound appears inflamed and exudes a thin, purulent, odorifer- 
ous discharge. If the coaptating stitches are removed, which of course 
should be done immediately, the escape of fecal matter may occur ; or, which 
is more frequently the case, a day or two later. Such a complication 
occurring in a newly made wound produces suppuration. The irritating 
discharges from the fistula cause a dermatitis of the surrounding skin. The 
odor becomes unbearable and necessitates frequent change of dressings. 

Treatment. — The large majority of fecal fistulae heal without surgical 
interference if kept cleansed with mild antiseptic solutions. The sinus 
itself should not be irrigated before the end of the first week through fear 
of disturbing the protective adhesions which have been thrown out; and 
even then the irrigating solution must be allowed to flow very gently. A 
liquid diet is maintained so as to leave as little residue in the bowel as possi- 
ble. If these means fail to accomplish a cure a surgical operation is neces- 
sary. The skin around the fistula should be protected with zinc ointment 
to prevent an eczema developing from the irritating fecal discharges. 

Erysipelas. — This is an acute infectious disease characterized by inflam- 
mation of the skin and mucous membrane; the result of the presence of the 
streptococcus. In the pre-antiseptic age this was one of the most common 



Erysipelas — Causes — Symptoms 243 

surgical complications. Modern ideas of isolation and present methods of 
wound treatment have made it one of the rarest sequelae encountered. 

Causes. — There are two causative factors in the production of erysipelas, 
viz., (1) a breach of surface continuity, and (2) the entrance therein and 
the multiplication of the streptococcus. 

It is not the province of this lecture to enter into a discussion whether 
there is a specific variety of the streptococcus which produces erysipelas ; 
some authorities claim there is, others assert it is the ordinary pyogenic 
.streptococcus found in other inflammatory conditions. The question has 
not yet been definitely settled. In the vast majority of cases the erysip- 
elatous inflammation is confined to the skin, but in the more severe types the 
deeper tissues are involved. 

Symptoms. — As a rule there are no premonitory constitutional symptoms. 
From one to three days after an accident has been received a chill makes its 
appearance; followed by a rise in temperature and a proportionate pulse 
rate. A reddish blush appears from one of the edges of the wound or abra- 
sion, extending forward in the natural skin ; its margins clean cut and indi- 
cating the path taken by the infection. This redness continues to extend, 
and at times involves a large surface. In other instances red streaks "jut 
out" from the main area, indicating the course of the superficial lymphatics 
The patient complains of a burning pain and itching at the site of inflamma- 
tion. Palpation of the inflamed part reveals a tension over this blush when 
compared with the soft elastic feeling of normal tissue. If pressure is made 
by the examining finger on the erysipelatous area, the red color disappears 
momentarily and gives place to a yellowish tint; immediately however the 
redness reappears. In the severer froms the infected surface is slightly 
raised ; vesicles or blebs form, from which a thin serous exudation escapes. 
If the erysipelatous infection is situated in loose tissue, as in the face for in- 
stance, great swelling ensues ; the eyelids become edematous, and the ex- 
pression greatly distorted. The tendency of the disease is to spread by con- 
tinuity of tissue. Constitutional symptoms occasionally develop before the 
local signs I have described, but this is not the rule. The temperature which 
succeeds the initial chill does not recede as in septicemia and pyemia, but 
remains the same or possibly higher. This peculiarity is considered diag- 
nostic. Occasionally the fever is intermittent or remittent. After the de- 
velopment of the infection such general symptoms as headache, pain in the 
limbs and joints, and digestive disturbances make their appearance. // the 
local infection becomes general the constitutional symptoms are proportion- 
ately severe; the coated tongue becomes dry and bleeds easily, sordes ac- 
cumulate on the teeth and lips, muscular twitchings and low-muttering 



244 Treatment — Nurse's Duties 

delirium develop as the result of the toxemia. The usual complications 
found in the deeper organs are not as frequent as in other infections. 

Treatment. — The erysipelatous patient should be isolated, in spite of the 
fact that some surgical authorities claim that it is unnecessary. 

Local — Drugs applied locally have very little influence on the course of 
the disease. Moist dressings of carbolic acid 1 per cent., or corrosive sub- 
limate 1 :2000, or a 25-per cent, mixture of ichthyol and ethereal collodion are 
used. Bier's hyperemic treatment has given me the best results. (See lec- 
ture on "Surgery, Surgical Nursing, Infection," etc., section "Bier's 
Hyperemic Treatment.") 

Constitutional. — Some surgeons advocate injections of the antistrep- 
tococcic serum. The internal administration of drugs has not given satis- 
factory results. A nutritious liquid dietary, laxatives, and tepid bathing to 
reduce the temperature, is the indicated treatment in the majority of cases. 
In the more severe types alcoholic stimulation and the use of rectal infusions 
are in order. 

Nurse's Duties. — Septicemia, pyemia, and erysipelas are exceedingly in- 
fectious diseases which are capable of being communicated to other surgical 
patients through the careless work of a nurse and improper technic. The 
greatest care therefore should be exercised to prevent the carrying of infec- 
tion from the affected patient to others. In fact it is highly proper for a 
special nurse to have exclusive care of patients suffering from these dis- 
eases, and not be aUozvcd to mingle with the other nurses or assist in the 
dressings of other surgical cases. Moreover the eating and drinking utensils 
of such patients should be kept exclusively for their use and not indiscrimi- 
nately placed around to be used by others. The face towels, nightgowns, 
bedclothing, and nurse's outfit should be boiled previous to being sent to the 
general laundry. The basins, douchecans, and rubber gloves employed in 
the case should not be laid aside with a promise of future sterilization, but 
should immediately go through such process. The dressings which are 
changed from day to day should at once be cremated. The same careful 
technic in the personal toilet of the nurse, especially in the use of gloves and 
gowns, is compulsory. The preparation of the solutions, basins, and 
douches as have been previously described should be carried out to prevent 
any secondary infection. Simply because a patient is suffering from an 
infectious disease is no reason why the same care should not be exercised 
as though no infection were present. In fact it is your duty to be all the 
more careful in your manipulations. The room occupied by the patient 
should be thoroughly fumigated before being used again by another. 



Tetanus — Lockjaw 245 

Tetanus — Lockjaw. — This is an infectious disease characterized by 
spasms of the voluntary muscles, due to the effects of a toxin on the spinal 
cord and medulla. The toxin is derived from the tetanus bacillus. 

Acute tetanus or lockjaw is an exceedingly uncommon postoperative com- 
plication and is only mentioned in this connection because of certain pecu- 
liarities connected with the disease, which if understood, assist the nurse 
to a great extent in caring for the patient. 

The mode of entrance into the economy in the large majority of cases 
is through the medium of a wound. The tetanus bacillus can only develop 
in a location where atmospheric air is excluded; that is to say, it is anaerobic 
(developing without oxygen), hence its effects are only manifested in the 
economy either after a wound has healed, or when an injury is of such a 
character as to prevent air from coming in contact with the bacillus — such 
as gunshot, stab, or punctured wounds. The natural habitat or home of the 
tetanus bacillus is in dust, dirt, and manure. The popular notion of the dan- 
gers of a wound produced by a rusty 1 nail has some philosophy in fact. This 
means of injury does not produce lockjaw because of its being rusty, but 
from the fact that it is liable to be covered with dust infected with the 
tetanus bacillus, and produces a zvound conducive to the exclusion of 
oxygen. On the other hand the nail or means by which a wound is pro- 
duced may not be contaminated with the tetanus bacillus, but the part 
wounded may be the resting place of such microorganism and entrance is 
gained into the economy either at the time of injury or subsequently. 

The impression that the cartridges of toy pistols are the source of infec- 
tion of the numerous cases of lockjaw which occur after the Fourth of July 
is erroneous. The dust and dirt on the hands of the victim is the medium 
through which the bacillus gains entrance after an injury has been received, 
whether it be from a toy pistol or other means of celebration 

It is possible that the tetanus bacillus may gain entrance into the economy 
through the respiratory, genital, or digestive systems, but these avenues are 
exceedingly rare. 

After entrance into the tissues has been gained and atmospheric air ex- 
cluded, other peculiarities of this microorganism are noted. No inflamma- 
tory action is observed around the point of invasion unless a mixed infection 
is present. The effects on the economy are not due to the propagation of 
the bacillus in the blood, nor to the development of pus, but to the elimina- 
tion of toxins. The wound may have healed entirely, or present a most 
harmless appearance, when the first signs of tetanus manifest themselves. 

To Meyer and Ranson, as quoted by Dr. Charles H. Frazier of Philadel- 
phia, the profession is indebted for the most important additions to our 



246 Tetanus — Symptoms 

knowledge of the manner of development of the disease. The following 
deductions have been made from the very excellent article of Dr. Frazier : 
The toxin of tetanus is carried to the spinal cord and medulla by way of 
the motor nerves; never through the sensory portion of the nervous system. 
After the toxins are eliminated locally the motor-nerve endings around the 
site of injury become the media by which a portion of the toxic material is 
transmitted to the cord. Other portions of the toxins in the wounded area 
are absorbed by the lympathics and eventually emptied into the blood- 
current. (See lecture on "Surgery, Surgical Nursing, Infection," etc., sec- 
tion "Lymphatic System.") The capillaries while performing their normal 
function of disseminating the nutritive principles of the blood to the various 
tissues also eliminate these toxins, which are absorbed by other motor-nerve 
endings and a similar process of transmission of this poisonous material to 
the cord occurs ; so that this toxic principle is reaching the motor tracts in 
the cord not only from the motor nerves at the original site of injury; but 
from motor-nerve terminals situated all over the economy. Having entered 
the cord the toxin spreads upwards until the medulla is reached. The action 
on the cord is simply one of excessive excitability on the motor tracts. The 
sensory portion of the cord is affected by reflex action. 

Symptoms. — The symptoms manifest themselves between seven and ten 
days from the time of the wound, during which period several conditions 
are developing — 

(1) The exclusion of atmospheric air around the tetanus bacilli to permit 
their development. 

(2) The elimination of toxins. 

(3) The absorption and conduction of these toxins to the cord by the 
motor nerves. 

The disease therefore is practically developed before its true signs are 
manifested. As a rule the first symptom is a stiffness of the neck, which is 
shortly followd by a rigidity of the muscles of the jaw (trismus), so that 
the patient is unable to turn the head from side to side or open the mouth. 
Spasms of the muscles of the face develop, producing that peculiar ex- 
pression known as "risus sardonicus." The muscles of deglutition become 
rigid, as well as those of the abdomen and extremities. Contraction of the 
muscles of the back develops to the extent that the patient is arched like a 
bow and lies on his heels and occiput (opisthotonos), or assumes other con- 
torted positions. The picture thus far is one of tonic spasm; that is to say, 
a condition of continuous rigidity and contraction of the muscles. Through 
some peripheral irritation such as a sudden noise, jarring of the bed, drafts 
of air, hypodermatic medication, the condition is changed to one of clonic 
convulsions, by which is understood alternating contraction and relaxation 



Tetanus — Prognosis — Treatment 247 

of the muscular system. These convulsive seizures vary in frequency and 
duration and are accompanied by pain of a very agonizing character. 
On account of the rigidity of the muscles of deglutition and mastication 
only liquid nourishment can be given, and even this is swallowed with great 
difficulty. Difficult breathing (dyspnea), as would be expected, is present 
because of the rigidity of the muscles of respiration and the spasms of the 
diaphragm and glottis. Profuse sweats bathe the patient. Constipation and 
retention of urine are common. Throughout the continual tonic and clonic 
spasms the patient's mind remains clear with a perfect realization of his 
true condition, and with the added misfortune of being unable to articulate. 
The temperature at first is slightly elevated, but rises generally before 
death. 

Chronic Tetanus. — Formerly by this term was understood a prolonged 
period of incubation, while the modern acceptation implies the duration of 
the disease, which is certainly the more correct interpretation. The symp- 
toms of this form are the same as those seen in acute tetanus, only not as 
pronounced and with longer intervals between the convulsive seizures, af- 
fording the patient an opportunity for recuperation and obtaining nourish- 
ment. Relapses are occasionally seen. 

Prognosis. — This is unfavorable in acute tetanus, but with the present 
knowledge of the manner in which the toxin is disseminated and the proper 
technic in the administration of the antitoxin, the profession is in a better 
position to appreciate the avenues by which the toxic material should be 
attacked. For this reason I think the mortality in the future will be reduced. 
The longer the duration of the disease the more favorable is the outlook. 

Treatment — Local. — Prophylaxis should play an important part. When 
any wound has been received of such a character as to prevent a thorough 
ablution of its cavity, it should be immediately laid open so that all recesses 
can be cleansed, damaged tissue removed, and a free exit afforded for dis- 
charges. This is especially indicated when the environment and condition 
of the patient at the time of the injury are of a nature to suggest the possi- 
bility of such an infection occurring as the one tinder consideration. In ad- 
dition immunization of the patient by injections of antitoxin at the site of 
injury and intravenously should be made; the frequency of repetition de- 
pending on the views of the surgeon. 

Unfortunately in all cases which have come under my observation, and I 
suspect the same is true in the experience of other surgeons, the injury has 
been of such minor importance that the patient paid no attention to it until 
the constitutional signs of tetanus developed. At this stage local treatment is 
compulsory even though the wound has healed. A careful dissection of the 
part should be made in an endeavor to remove the base of supply from 



248 Tetanus — Constitutional Treatment 

which the toxins are eliminated, followed by thorough irrigations of the 
wound with a 2-per cent, carbolic-acid or tincture-of-iodin solution. Iodo- 
form gauze is used as a dressing as in other infected wounds. Caustics are 
positively contra-indicated, inasmuch as these coagulate an albuminous 
deposit, forming a shelter for the bacilli by excluding air, and favoring their 
development. 

Constitutional Treatment. — I shall not attempt to describe the various 
methods which have been advocated, but confine my remarks to the treat- 
ment with antitoxin, as I am firmly convinced this will be the means adopted 
in the future. As far as is known the tetanus antitoxin is not absorbed at 
all by the nerves. It is therefore necessary to introduce, the antitoxin 
directly into the nerve to block the course of the toxin. 

The summary of our knowledge therefore is as follows : 

(1) The motor nerves are the paths of transmission by which the toxin 
reaches the cord. 

(2) The toxin comes in contact primarily with the motor-nerve endings 
at the site of injury. 

(3) The toxin reaches other motor-nerve terminals secondarily by way 
of the circulation. 

(4) The antitoxin is not absorbed by the nerves ; hence it is necessary 
to introduce it mechanically. 

With this knowledge, the philosophy of the plan of injections as utilized 
by Rogers can be appreciated — 

(1) The subcutaneous injections at the site of injury to render inert the 
toxins present. 

(2) Intravenous injections to neutralize the toxins in the blood-current. 

(3) The direct injections of the antitoxin into the nerve supplying the 
member which received the primary injury to block the course of the toxin. 

(4) The direct injections of the antitoxin into the cord at a suitable level 
to protect the vital centers in the medulla from further invasion by the 
toxin. 

The injections of the antitoxin should be made daily, or even twice a day, 
because its elimination from the body is very rapid and only a small amount 
is absorbed. The dose is ad libitum, as the serum is perfectly harmless. 
These are matters which concern the surgeon exclusively. Intravenous 
injections of normal salt solution are utilized to favor the elimination of 
the toxins. 

Drugs. — Of all the numerous drugs which have been recommended 
chloral hydrate and morphin are possibly the best. These are administered 



Tetanus — Diet — General Measures 249 

in an endeavor to prevent the paroxysmal seizures ; the former is frequently 
given per rectum in solution, while the latter is administered hypoder- 
matically. If these medicinal agents are ineffectual chloroform anesthesia 
is employed with the same end in view, — to afford the patient rest. 

Diet. — A liquid and highly nutritious diet is indicated. If the muscles of 
deglutition permit of swallowing, food is administered by the mouth, other- 
wise nutrient enemata are resorted to. 

General Measures. — The patient should be placed in a dark room, remote 
from noise and other irritations which are known to influence the convulsive 
seizures. Friends and relatives should be excluded. Catheterization is fre- 
quently necessary because of the rigidity of the sphincter of the bladder. 
Attention must be paid to the evacuation of the bowel. 

Nurse's Duties. — These are self-evident. 

BIBLIOGRAPHY. 
Operative Gynecology — Howard A. Kelly, A. B., M. D., LL. D. 
The Peritoneum — Byron Robinson, B. S., M. D. 
Modern Surgery — J. Chalmers DaCosta, M. D. 
Keen's Surgery — Charles Harrison Frazier, M. D. 



LECTURE XXIV 

MAJOR SURGERY IN PRIVATE PRACTICE 

It frequently becomes necessary for the surgeon to forego the many con- 
veniences afforded by a hospital for operating and to improvise an operat- 
ing-room at the home of the patient, in many cases miles remote from his 
base of supplies, and often far distant even from the country drug store. 
Unless the case be one whose physical condition prohibits transportation, 
the patient should always be brought to the hospital where the surgeon is 
accustomed to operate. The reasons for this should be self-evident, because 
whatever care is exercised in carrying out the many details necessary for 
the preparation of an operation at the home of the patient, danger of break- 
ing the "chain of asepsis" is constantly present ; the various makeshifts that 
are utilized curtail to a great extent the surgeon's freedom; the after- 
treatment is not under the supervision of the attending surgeon, — a point 
of infinite importance in the final results. 

This is the occasion of all occasions when the surgeon should .surround 
himself with such assistants and nurses as are familiar with his technic, 
and on whom he can rely implicitly to carry out the multitudinous details 
which will arise. His usual hospital assistants accompany him on the day 
of operation ; the nurse is selected and dispatched to the home of the patient 
the day previous, if the exigencies of the case permit. 

Nurse's Immediate Duties. — (1) Ascertain the full name and address of 
the patient, the facilities for transportation, whether provisions have been 
made for your reception at the depot, and if not, get directions for reaching 
your destination. This may seem superfluous, but it is not. 

(2) Unless thoroughly acquainted with the surgeon's technic, ascertain 
the following facts : 

(a) His method of preparing the field of operation. 

(b) His views of hand sterilization. 

(c) The character of the diet to be given the patient the day previous 

to operation. 

(d) The kind of cathartic desired administered to the patient. 

(250) 



Nurse's Immediate Duties 251 

(e) The hour scheduled for the operation. 

(f) Whether morhpin gr. 1/4, atropin gr. 1/150 (or hyoscin gr. 1/200) 

is to be administered before time set for operation. 

(g) Ascertain the position in bed the surgeon desires the patient to 

assume immediately after the operation. 

(3) Have a thorough understanding with the surgeon as to what articles 
yon will be expected to take, and those he will be responsible for. As a rule 
the surgeon is connected with some hospital where he is in position to obtain 
the necessary dressings, sponges, towels, gowns, caps, etc., already sterilized 
in properly protected packages. It will be more convenient therefore for 
him to assume the responsibility for these articles, but such necessities as 
sheets and blankets the nurse should procure from the patient's home, while 
the towels are especially included in the hospital packages the surgeon will 
bring because they will be more thoroughly sterilized. 

(4) Purchase the following supplies : 

(a) 100 mercuric tablets. 

(b) 100 normal saline tablets. 

(c) 8 5 carbolic acid. 

(d) 4 5 tincture iodin. 

(e) 4 3 solution adrenalin. 

(f) 2 pints alcohol. 

(g) 1 pint brandy or whiskey, 
(h) 1 paper safety pins. 

(i) 4 ordinary wooden hand brushes. 

(j) 5 yards of plain sterile gauze which will be needed before the sur- 
geon arrives with the hospital supplies, 
(k) 1 yard rubber sheeting. 

(1) Such other articles as are necessary for the sterilization of hands 

and field of operation according to the views of the surgeon, 

which you have already learned. 

I have purposely omitted green soap or tincture of green soap because 

the ordinary laundry soap answers all purposes admirably. Such a list as 

has been suggested should be neatly typewritten and pasted inside the 

nurse's grip, satchel, or suit case as a check that nothing has been omitted. 

Obtain a receipted bill for the above articles and present it to the head of 
the family at an appropriate time ; this will in no way disparage you, but only 
demonstrate your businesslike methods. 



252 Surgeon's Outfit 

(5) Prepare your professional equipment by including the following 
articles : 

(a) 2 pairs rubber gloves. 

(b) 2 operating-gowns and 1 operating-cap previously sterilized. 

(c) 1 porcelain douchecan equipped with rubber tubing, appropriate 

nozzles for rectal enemata, proctoclysis, and vaginal douches, and 
which will serve the purpose for an infusion reservoir if needed. 

(d) 1 infusion needle. 

(e) 1 soft rubber catheter (about 17 French), 1 glass female catheter, 1 

rectal or colon tube. 

(f) 1 collapsible tube of sterilized vaselin. 

(g) 1 safety razor, or a depilatory powder according to the formula 

given in the lecture on "Preparation of Patient for Operation." 
(h) 1 clinical thermometer. 
( i ) 1 pair of bandage scissors, 1 pair of sharp-pointed scissors, 1 pair 

of dissecting forceps, 
(j) 1 hypodermic syringe, fully equipped with the following tablets: 

Strychnin sulphate gr. 1/30. 

Morphin (plain) gr. 1/4. 

Morphin gr. 1/4-atropin gr. 1/150; or morphin gr. 1/4-hyoscin 
1/200. 

Digitalin gr. 1/60. 
(k) Hot-water bottles may be included, but the common beer bottle 

with self-retaining stopper, or the ordinary mason jar as found 

in every household, answers admirably as a substitute. 

Surgeon's Outfit. — In order that there shall be no misunderstanding this 
will include: 

(a) Operating instruments and needles, besides various kinds and sizes 

of suture and ligature material. 

(b) Sterilized suits, gowns, caps, and gloves for himself and assistants. 

(c) Sterilized dressings, sponges, towels, bandages, or abdominal binder 

in original protective packages. Possibly a jar of iodoform 
gauze. 

(d) Adhesive plaster and drainage tubes. 

(e) Kelly pad (optional). 

(f) Anesthetic, inhalers and cones. 

Some surgeons add a skeleton table, or a Trendelenberg frame (which 
latter can be adjusted to an ordinary kitchen table) to this list of supplies. 



Preparation of Room 253 

It should be previously understood if these will be brought by the surgeon 
or substitutes provided in a way to be described later. 

Duties of the Nurse on Arrival at the Home of the Patient. — At once 
endeavor to gain the confidence of your patient and demonstrate to 
the family that instead of being a useless appendage, your presence is a 
necessity. Remember in all the details that are carried out to perfect a 
"chain of asepsis" you will constantly be in contact with persons, who, while 
willing to assist, are utterly ignorant of the first principles of true asepsis. 
Be kind and considerate, yet firm in your views, and ever watchful that the 
labor expended in sterilizing necessary articles, cleansing furniture, etc., 
does not go for naught by the thoughtless interference of some one: in 
short, be the executive in the absence of the surgeon. 

Extemporized Operating-room. — Frequently the surgeon makes the se- 
lection of the temporary operating-room at his first visit, but occasionally 
it becomes the duty of the nurse. In selecting such an apartment there are 
several factors to be taken into consideration, such as the location, size, and 
facilities for light. Therefore choose — 

(1) A large and commodious apartment. 

(2) Remote from the noise of the general living-room and where mor- 
bidly curious visitors can be shut out. 

(3) With a northern exposure if possible; if this cannot be obtained, an 
eastern exposure for morning, and a western for afternoon operations. 

(4) A room that has not been lately occupied by a patient with some 
acute infectious disease. (See double-page illustration LV.) 

Preparation of the Room (when time will permit).— 

(1) Remove all furniture, carpets, curtains, window shades, and pictures. 

(2) If the operation occurs during cold weather and the room is heated 
by an open fire, substitute a closed stove if possible, if chloroform is to be 
the anesthetic employed which occasionally is the case, as the fumes from 
this drug mixing with the open fire produce a gas which is exceedingly irri- 
tating; in fact I have witnessed a partial asphyxiation from this source. 
Cloths moistened in ammonia water and hung around the room will neutral- 
ize the effects of these irritating fumes. 

(3) With an ordinary straw broom covered with a clean cloth, frequently 
changed, sweep the ceiling and walls of the apartment thoroughly and 
systematically. 

(4) With soap and water wash the woodwork and windows, paying strict 
attention to such portions as favor the accumulation of dust, such as the 



254 Necessary Articles 

caps of doors, windows, and mantel. Chemical antiseptics must not be used, 
as these spoil the finish of the wood and subject the nurse to criticism. 

(5) Have the floor thoroughly scrubbed with soap and water, and finally 
mop it with a solution of mercury 1 :1000, or carbolic acid 1 :20. If the floor 
is of the modern hard-wood type omit the antiseptics. 

(6) In order to obstruct the view of outsiders and not interfere with the 
entrance of light, frost the lower half of the windows with a paste made of 
pipe clay or soap, or sash curtains of thin material may be adjusted. 

(7) Open the windows to allow the room to thoroughly air for two or 
three hours. 

(8) Close and lock the door of the apartment. 

A List of Necessary Articles. — 

(a) 1 ordinary kitchen-table to be used for an operating-table. If the 

Trendelenberg position is to be utilized reinforce the legs by nail- 
ing cleats from one to the other. In addition have made a sub- 
stantial box, 10 inches high, 10 inches wide, and a little longer 
than the width of the table to serve as an elevator for one end of 
the table to produce the desired position. If the table is not long 
enough any ordinary carpenter can easily make an extension. A 
dining-room table is unfit for surgical operations because of its 
extreme width. 

(b) 1 large table for sponges and ligatures. 

(c) 1 small stand (marble top preferred) for instruments. 

(d) 1 bench for the basins in which the surgeon and assistants make 

their primary toilet. 

(e) 2 small chairs, one for the anesthetist and the other for the surgeon 

if the operation be on the vagina, rectum, etc. 

f 2 for surgeon's hands when making his toilet. 

(f) 6 basins J 2 for surgeon's hands during the operation. 

[2 for sponges. 



(g) 4 pitchers 



2 to contain saline solutions for sponges. 
1 to contain sterile water. 

1 to contain mercuric solution 1 :2000, for the prep- 
aration of the surgreon's and assistant's hands. 



(h) 1 porcelain douchecan. 

(i) 1 laundry tub as a waste receptacle. 

(j) 1 slopjar to receive the drainage from the Kelly pad if one is used. 

(k) 2 wash boilers for hot and cold sterile water. 



Necessary Articles — Sterilization 255 

(1) 1 long-handled dipper to be used with the sterile water in the 
boilers. 

, s _ , « , f 1 large, with which to pad the operating-table, 
(m) 3 blanketsJ 8 ' ^ 4 .- F . ' j T . 8 

1 2 small, to protect the patient during the operation. 

1 to be used as a cover for the operating-table. 

1 to be utilized in a similar manner for the sponge- 
and ligature-table, 
(n) 3 sheets -{ 1 as an operating sheet. If the case is a celiotomy 
an oblong aperture is cut in the center to corre- 
spond with the site of the operation (so-called 
celiotomy sheet). 

(o) 1 small pillow and corresponding muslin slip, 
(p) 1 yard rubber sheeting (purchased by the nurse), 
(q) 4 wooden hand brushes (purchased by the nurse). 
Up to this point the temporary operating-room has been prepared and 
such articles selected as will be necessary to furnish it. 

Sterilization. — 

(1) The tables and chairs are thoroughly scrubbed with soap, water, and 
brush, then rinsed with a solution of bichlorid of mercury 1 -.1000, or car- 
bolic acid 1 :20, the latter being preferable as less liable to damage the finish 
of the furniture. 

(2) Remove to the operating-room immediately. 

(3) The basins, pitchers, and douchecan are washed thoroughly in soap 
and water, rinsed in boiling water, placed in the operating-room and filled 
with mercuric solution 1 :2000 or carbolic acid 1 :20, where they remain until 
the next morning. This is the best means of sterilizing these articles as the 
ordinary household does not have a receptacle large enough to boil them in, 
and the usual recommendation to submerge them in the bathtub is fre- 
quently not practical. 

(4) The laundry tub and slop jar which are to serve as waste receptacles 
are simply scrubbed with soap and water and immediately placed in the 
operating-room. 

(5) The wash boilers go through a very careful scrubbing, are then 
rinsed and scalded, filled with hard water (not the dirty cistern water so 
commonly used), and placed on the stove to boil for twenty minutes. The 
dipper is sterilized by being suspended in one of the boilers. They are then 
removed to the operating-room. 

(6) The sheets, blankets, and pillow-case are wrapped in separate covers, 
placed in the ordinary oven, the door of which is left slightly ajar, and 



256 Preparation of Patient — Nurse's Duties 

sterilized by the "fractional method," which has already been described in 
the lecture on "Antiseptics, Disinfectants, Germicides," etc., section "Ster- 
ilization by Heat." After being sterilized remove these articles to the 
operating-room. 

If the surgeon decides not to bring towels, then the same must be secured 
at the home of the patient and sterilized in the same manner as the sheets, 
blankets, etc. There should be at least 12 or 15 of these articles. 

(7) The rubber sheeting is washed with soap and water, then sponged 
thoroughly with mercuric or carbolic solution. 

(8) The hand brushes after being enclosed in a wrapper are boiled. 

Preparation of the Patient. — This has been given in detail in the lecture 
devoted to this subject. Some slight modifications may be required by the 
attending surgeon, but the basic principles involved will be the same. The 
necessary equipment such as soap, brush, antiseptics, alcohol, etc., are at 
hand. After the field of operation has been prepared, protect the same with 
several layers of the plain sterile gauze which was purchased with the sup- 
plies, and hold in place with an improvised abdominal binder (roller towel). 

Preparation of the Patient's Bed. — If the operating-room is large and 
commodious it is frequently used as the future bedroom of the patient; 
under such circumstances, after the bed is prepared it is placed in one corner 
of the room. If the room is small it is better to have a separate apartment. 

(1) Select a single iron bedstead if possible, with a good mattress. 

(2) Thoroughly wash the bedstead with soap and water. 

(3) Air the mattress and pillows. 

(4) Assemble the bedstead. 

(5) Prepare the bed according to hospital custom, details of which have 
been given you. 

(6) If the Fowler position is to be used an extemporized back-rest must 
be provided, which is easily accomplished by utilizing a chair turned upside 
down and padded with pillows, or an elevator made similar to the pattern 
already described. (See lecture on "Principles and Practice of Postopera- 
tive Nursing," section "Preparation of the Fowler Position.") 

Nurse's Duties the Day of the Operation. — If the various steps given 
you have been carefully carried out a couple of hours will be ample time 
to complete the final details, which will be as follows : 

(1) Assume a clean gown and cap and thoroughly prepare your hands 
without gloves. 

(2) Have one of the boilers of sterile water placed on the stove heated to 
the boiling point and then returned to the operating-room beside the boiler 




Illustr. 
An Extemporized Operating-room. — Note the elevation of the operating-table byi 






x LV 

ans of a box or block of wood in order to obtain the Trendelenberg- posture 



Preparation of Patient — Nurse's Duties 257 

containing the cold sterile water, — thus the temperature of the different 
solutions can be regulated. Locate both convenient to the sponge-table. 

(3) Place the operating-table in the most advantageous light. 

(4) Arrange sponge-table and instrument-stand according to hospital 
custom, i. e., one on either side of the operating-table. 

(5) Locate the basin bench in a remote part of the room. 

(6) Locate the laundry tub in a convenient position to the sponge-table. 

(7) Cover the sponge-table with one of the sterilized sheets. 

(8) Empty the basins and pitchers filled the day previous with antiseptic 
solutions, and rinse them thoroughly in sterile water. 

(9) Thoroughly cleanse the outside of the bottles containing the various 
antiseptics, etc. With clean hands tie a piece of sterile gauze around each 
container. 

(10) Locate on the sponge-table the following: 
(a) Bottles containing antiseptics, etc. 

2 for sponges. 



1 2 for surgeon's hands during operation. 

(c) 2 pitchers for saline solutions to replenish sponge-basins. 

(d) The dressings, sponges, etc., which the surgeon will provide. 

(e) The small blankets and celiotomy sheet which cover the patient 

during the operation. 

(11) The instrument-stand will be covered with sterile towels provided 
by the surgeon, previous to the instruments being placed thereon. 

(12) On the basin bench are placed the following: 
(a) 2 basins. 

. . , f 1 for sterile water. 

^ ' ^ 1 1 for mercuric solution 1 :2000. 

(c) Muslin wrapper containing hand brushes. 

(d) Soap. 

(e) Such special antiseptics as the individual surgeon employs for 

hand sterilization. 

(13) Prepare the operating-table as follows: 

(a) Cushion the top with the large blanket folded to fit. 

(b) Protect the blanket with rubber sheeting. 

(c) Cover this latter with the sterile muslin sheet which should be 

tucked under the table and securely pinned. 

(d) Inclose the small pillow in the sterile slip and place in position. 

(e) Elevate the foot of the table with the box provided for that pur- 

pose, if the Trendelenberg position is to be used. This is espe- 
cially necessary in obese patients. * - 



258 Fixal Preparation of Field 

(14) In these many steps which have been taken the nurse should have 
paid strict attention to her hands by frequent washing. 

On the arrival of the surgeon several duties devolve on the nurse. 

(1) The hospital supplies brought by the surgeon are located in their 
proper places. 

(2) Cover top of instrument-stand with towels, on which the assistant 
will immediately arrange the instruments. 

(3) Prepare solutions as follows (these have been left to the last so that 
they may be warm when needed I : 

(a) 2 pitchers filled with normal saline solution to be used in the 

sponge basins. 

(b) 2 pitchers, one rilled with mercuric solution and the other with 

plain sterile water for the sterilization of the surgeon's hands. 

(c) The solutions in the basins for the surgeon's use during the opera- 

tion must be replenished frequently. Mercuric solution 1 :2000 
will be required in one and normal saline solution in the other. 
After the surgeon's and assistants' toilets are completed and during the 

time the patient is being anesthetized, the nurse makes her own personal 

toilet as follows : 

(1) Sterilize hands. 

(2) Assume clean gown and two pairs of gloves. 

Final Preparation of Field of Operation. — The patient being anes- 
thetized and placed on the table the nurse carries out the following schedule : 

(1) Surround the patient with the small blankets in such a manner as to 
leave the field of operation exposed. 

(2) Cover blankets with sterile towels. 

(3) Remove protective dressings. 

(4) Cleanse the held of operation according to the surgeon's views. 

(5) Cover the patient with the sterile muslin sheet; if the case be 
a celiotomy an aperture is made in the sheet corresponding with the held of 
operation. 

( 6 ) Remove outer pair of gloves and assume bib-apron. 

Nurse's Duties During Operation. — 

(1) Handle sponges and keep correct count of the same, if the case is a 
celiotomy. 

(2) Replenish solutions when needed. 

(3) Prepare ligatures and sutures if required to do so. 

(4) Assist with the final dressings. 



Preparation of Temporary Operatixg-room 259 

Preparation of the Temporary Operating-room when time is limited. — 
Occasionally, as in emergency cases, time will be so limited as to prevent 
a thorough preparation of the room. Under such circumstances carry out 
the following schedule : 

(1) Remove only such furniture as necessary to afford free working 
space. 

(2) Do not disturb the carpet, shades, curtains, or pictures, as in so doing 
the dust created will act as a medium for infection. • 

(3) Cover the carpet with moist sheets. Some surgeons require all furni- 
ture left in the room to be draped. 

(4) If the operation occurs in the daytime, roll up the window shades 
and carefully drape back the curtains so as to permit as free light as possi- 
ble ; if at night, make provisions for artificial light. 

Sterilization. — The cleansing of the extemporized operating-table and 
other stands which will be used, and the sterilization of the various articles 
which the household furnishes cannot be as thoroughly accomplished as 
when time is at our disposal, so that antiseptics play a greater part than on 
other occasions. 

A simple way of sterilizing the basins and pitchers is the following : 

(1) Scrub these articles thoroughly with soap and water. 

(2) Rinse and dry thoroughly. 

(3) Moisten the inner surface with alcohol and touch with a lighted 
match, care being taken to cause the flame to cover the inside of the vessel 
so that the heat will be equitably diffused, and thus prevent the utensil 
from breaking. However, use of the usual antiseptics for this purpose 
should be given the preference. 



LECTURE XXV 

GENERAL ANESTHESIA— ANESTHETICS 

Introduction. — I have been undecided whether a series of lectures to 
nurses should include the subject of anesthesia. After consideration I have 
concluded to give what may be termed the stepping-stones, or first princi- 
ples, of this important subject. I do not think for one moment that all of 
you will become anesthetists, and possibly no individual of this class may 
undertake to especially equip herself for this important duty, but any of 
you may be called upon to administer an anesthetic in an emergency. It is 
on account of such exigencies that may occur in your professional life that 
I invite your attention to this subject. At the present time a few of the best 
surgeons of the country are employing specially trained nurses as their anes- 
thetists, because they realize that the large majority of physicians who 
undertake this special line of work sooner or later relinquish it for what 
appears to them a more remunerative field. I do not consider it appro- 
priate to enter into a discussion as to the merits or demerits of the specially 
trained nurse-anesthetist. The few who have come under my observation 
have shown a dexterity in their work which, to say the least, has been very 
gratifying. 

The principles on which the administration of anesthetics are based are 
founded on the knowledge of physiology, anatomy, and pathology, especially 
of the circulatory and respiratory systems. Moreover, the anesthetist should 
be thoroughly conversant not only with the physiologic action of the various 
drugs used to induce anesthesia, but the effects produced by such alkaloidal 
narcotics as are frequently employed in combination with general anes- 
thetics. With such a foundation, the anesthetist is qualified to choose the 
proper anesthetic in a given case and proportionately to safeguard the 
patient. Dexterity in the administration of anesthetics must first be gained 
in the Kindergarten of Observation, supplemented by laboratory experi- 
ments on lower animals ; then in the School of Administration under the 
supervision of a skilled teacher; and finally, the student may attempt their 
practical administration. Refinement, dexterity, and a keen appreciation of 

(260) 



Introduction 261 

the various stages through which the patient passes when under the influence 
of these drugs are gained only by large and extensive practical experience. 

The time has passed, I hope, when the important duty of administering an 
anesthetic will be intrusted to the young and inexperienced college grad- 
uate, who as hospital intern hardly becomes efficient in the administration of 
these drugs before his term of service is ended, and his place filled by an- 
other inexperienced man who goes through the same experimental routine 
as his predecessor. In this way the lives of innocent and unsuspecting 
patients are jeopardized. Every hospital should afford an expert anes- 
thetist who should receive a remuneration in proportion to the services ren- 
dered. This extra outlay of money need not add any expense to the insti- 
tution. A patient who is willing to pay for an operation will be more than 
willing to pay a premium to one who can minimize the dangers of the anes- 
thetic. Moreover the charity patient should be given an equal protection. 
If the surgeon is willing to give his services to the unfortunate poor, the 
anesthetist of the institution should be as philanthropic. 

In connection with the trained versus the untrained anesthetist, Dr. E. H. 
Williams, San Francisco, Cal., in the St. Louis Medical Review (February, 
1911) makes the following analysis of 2,400 cases of anesthesia; — half of 
this number was administered by untrained interns, the other half by a 
qualified anesthetist or by trained interns : 

"(1) The untrained interns used over three times more ether. They 
averaged over three-fifths pound an hour as against less than one-fifth 
pound an hour used by the anesthetist. 

"(2) They stimulated six times as many patients during operation, using 
twenty times the number of stimulants in all. 

"(3) They had 41 per cent, more postoperative vomiting and this lasted 
much longer, often continuing for a number of days." 

From my personal observation I am fully convinced that the above figures 
are in no way exaggerated, and they are cited simply to corroborate the 
statements already made that the administration of these drugs should be 
restricted as far as possible to the specialist. 

In describing the administration of ether and chloroform I wish it to be 
understood that I have mentioned only the simplest methods. I have omit- 
ted the various forms of apparatus which have been designed for the admin- 
istration of these drugs, some of which are entirely too elaborate for the 
student to comprehend; others are practical, but they are intended for the 
skilled anesthetist. Likewise, I have not mentioned the use of oxygen in 
connection with ether and chloroform, — a combination which I think de- 
serves more consideration than has been accorded it. Nor have I touched 
on the subject of the administration of warm chloroform and ether instead 



262 Historical 

of utilizing these drugs at ordinary temperature. I am fully convinced the 
time is coming when the profession will appreciate the increased safety to 
the patient when the vapors of these drugs are employed warm. 

Historical. — By the term anesthesia in surgery is understood the loss of 
sensibility of a local part (local anesthesia), or of the entire body (general 
anesthesia), produced by the physiologic effects of drugs. Drugs capable of 
producing this condition are called anesthetics. 

To Dr. Oliver Wendell Holmes is due the honor of having suggested the 
terms anesthesia and anesthetic (1846). 

From the earliest times of which we have any record the efforts of man 
have been directed toward the relief of pain incident to disease, injury, or 
surgical operations. Mention is made of such remedial measures in the 
writings of the ancient Greeks, Romans, Arabians, Chinese, and Egyptians. 
Among the drugs then used were mandragora, belladonna, hyoscyamus, and 
cannabis indica ; later opium and alcohol were added to this list, and in fact 
ancient therapy was not dissimilar to ours up to the middle of the nineteenth 
century. Not only did the ancient physicians employ decoctions and infu- 
sions of drugs to alleviate pain, but they realized that the therapeutic action 
of these agents could be obtained by the inhalation of the fumes from burn- 
ing herbs. They also possessed some crude knowledge of physiology and 
pathology. They knew that anemia of the brain prohibited to a greater or 
less extent the functionating capacity of the cerebral centers, and employed 
compression of the carotid arteries to obtain a lessened sensibility during 
operative measures. They also advocated bleeding the patient until syncope 
resulted to alleviate the agonies of surgery. Pressure on nerve trunks, 
whose terminals innervated the field of operation, was next resorted to as a 
means of reducing pain. Hypnotism or mesmerism was next tried. This 
innovation was suggested and employed my Friederich (or Franz) Anton 
Mesmer (1735-1815), a German physician, who because of his studies in 
astrology at first claimed to cure disease and alleviate pain by means of mag- 
nets. Later, however, he professed to accomplish the same ends by an in- 
herent animal magnetism he possessed. Leaving Germany he went to Paris 
where he elicited intense interest. The Academy of Sciences of that city 
appointed a committee including Benjamin Franklin of this country to inves- 
tigate his methods. The report was unfavorable to Mesmer. Discouraged 
he went to London, finally returning to Germany, where he died. 

The historical data concerning our modern anesthetics are somewhat con- 
fusing, inasmuch as different authorities accredit the original discovery of 
nitrous oxid and ether to different individuals, besides varying as to dates. 
The research I have made, however, I think justifies the following conclu- 



Historical 263 

sions : Valerius Cordus discovered ether in 1540. Joseph Priestley (1733- 
1804), an English physicist and Unitarian divine, in 1774 discovered among 
other gases, oxygen and nitrous oxid. He was a man of letters and science ; 
took an active part in the public questions of the day, and was very out- 
spoken in his ideas on theology. The stand he took on these subjects 
aroused much bitterness and animosity. Other characteristics show him of 
a forgiving nature, and possessing the greatest liberality toward those who 
did not accept his views. Desiring to remove from the scenes of argument 
and strife with which he was surrounded he left England for America and 
settled at Northumberland, Pennsylvania. As is usual with such brilliant 
characters his true worth was not recognized until long after his death. The 
city of Birmingham, England, erected a marble statue of him in 1874. 

It is a peculiar historical fact that the discovery of nitrous oxid and 
oxygen was made by the same man and followed in quick sequence, and that 
even after the anesthetic properties of nitrous oxid were thoroughly appre- 
ciated by the profession its field of usefulness was limited until, by the addi- 
tion of oxygen, its range as an anesthetic became unlimited. The mixture of 
these gases was first suggested and utilized by Dr. Edmund Andrews of 
Chicago in 1868. 

Samuel Guthrie (1782-1848), an American chemist, discovered chloro- 
form in 1831. 

The discovery of nitrous oxid and ether did not add much to the therapy 
of the profession at that time, nor for years after. The effects of these 
drugs on the economy were only partially understood. Inhalation of ether 
was advised to relieve the suffering of tuberculosis, the spasmodic condition 
occurring in asthma, and other painful affections. Perira in 1839 in his 
work on "Materia Medica" counseled the danger of allowing a patient to 
inhale too much of the vapor of ether because of its stupefying effects. Sir 
Humphrey Davey (1778-1829), an English chemist, employed nitrous oxid 
to annul the pain of toothache, and in 1798 suggested its use as a means of 
relieving suffering in surgical operations. In addition experiments were 
made by the profession on the lower animals both with nitrous oxid and 
ether, yet with the clinical experience they possessed of the narcotic effects 
of ether and nitrous oxid, together with the results of their experiments on 
the lower animals, it seems incredible that the investigators of those days 
overlooked the anesthetic properties of these drugs. 

Nitrous Oxid. — An itinerant scientist named G. Q. Colton (1814-1898) 
visited Hartford, Connecticut, December 10, 1844, and "delivered a lecture on 
the same evening. One of the audience who had taken nitrous oxid for its 
exhilarating effects, fell and injured his leg without experiencing any pain. 



264 Historical 

Horace Wells (1815-1848), a dentist of the same city, witnessed the inci- 
dent, and immediately conceived the idea of using nitrous oxid as a means 
for relieving pain during the extraction of teeth. He was so firmly con- 
vinced of the usefulness of the gas under such circumstances that he per- 
suaded Colton to administer it to him the following day, at which time he 
had a tooth painlessly extracted. After successfully using it in his dental 
work, he obtained permission to demonstrate its efficacy at the Massachusetts 
General Hospital, but on account of an insufficient amount of gas anesthesia 
was not produced. Nitrous oxid then fell into disuse until 1863, when Colton 
induced dentists to utilize the gas. Four years later Colton published a 
record of 20,000 cases of successful anesthesia. To Wells therefore is at- 
tributed the honor of having first demonstrated the anesthetic properties of 
nitrous oxid. 

Ether. — The discovery of ether as an anesthetic is conceded to Dr. Wm. 
T. G. Morton (1819-1868), an American dentist. Morton was a student of 
Horace Wells, and afterwards became his partner in Boston. During his 
association with Wells he recognized the advantages derived from nitrous 
oxid as an anesthetic in dental surgery. On the dissolution of the partner- 
ship Morton requested Wells to disclose to him the methods he employed 
to manufacture nitrous oxid. Wells, who apparently had kept his process a 
secret, referred him to Dr. C. T. Jackson (1805-1880), a physician, but 
better known as a scientist, who had been associated with them. Jackson 
suggested to Morton the substitution of ether for nitrous oxid because of the 
facility with which the former could be made. Morton, acting on this sug- 
gestion, obtained some ether (history is not clear whether Jackson manu- 
factured it or not), and on September 30, 1846, painlessly extracted a tooth. 
The period of unconsciousness was so prolonged, however, as to alarm Mor- 
ton, and for some days he discontinued his experiments. On the memorable 
day of October 16, 1846, at the Massachusetts General Hospital, Morton suc- 
cessfully aministered ether to a patient from whom Dr. J. C. Warren (1778- 
1856) removed a tumor from the neck. Unfortunately, Morton, thinking 
only of self-aggrandizement and financial gain, combined aromatic oils with 
the ether to disguise it, and claimed for it the proprietary name of "Letheon." 
This unethical procedure prejudiced the profession against its use. The true 
nature of the anesthetic was soon suspected, and Morton admitted its 
identity. 

To complete the historical record of this anesthetic I must mention the 
name of Dr. Crawford W. Long (1816-1878) of Jefferson, Jackson County, 
Georgia, who in 1842 (four years previous to Morton's discovery) success- 
fully administered ether as an anesthetic and removed a tumor from the jaw 
of a patient. He appears to have subsequently employed this drug in his 




Illustration LVI 

The Anesthetizing-room. — Note the large entrance into the operating-room 
which facilitates the moving- of the patient to the surgery. See illustration 
XLIII for the relation of this room to the operating-room. 



(265) 



266 Field of Application 

surgical work. Unfortunately for Long as well as for humanity, he did not 
realize the immense scope of his discovery, but kept the results to himself 
and did not publish them until Morton s achievements became public. I think 
Dr. Long clearly demonstrated his claims as to priority. Inasmuch as Mor- 
ton made his discovery public, history accredits Morton the honor which he 
deserves. The controversies that ensued between Wells, Morton, Crawford, 
and Jackson as to the part each played -in the discovery of the anesthetic 
properties of nitrous oxid and ether form one of the darkest chapters in 
surgical literature. Time I think has made the following deductions : 

Dr. Crawford W. Long was the first to use any drug for the definite pur- 
pose of producing anesthesia, — this he accomplished with ether on March 30, 
1842. His discovery was not published until some years later. 

Dr. Horace Wells, a dentist, on December 11, 1844, persuaded a chemist 
by the name of Colton to administer nitrous oxid to him for the purpose of 
having a tooth painlessly extracted, with successful results. 

Dr. W. T. G. Morton, a dentist, successfully produced anesthesia with 
ether for the extraction of a tooth September 30, 1846, and on October 16 
of the same year made a public demonstration of the efficacy of ether as an 
anesthetic at the Massachusetts General Hospital. 

Dr. C. T. Jackson, a physician and scientist, first suggested the use of 
ether to Morton. 

Chloroform. — On account of improper inhalers, and possibly through fear 
in its administration, the anesthetic effects of ether were not uniformly ob- 
tained ; the consequence was that the leading surgeons of Great Britain were 
not very enthusiastic in its adoption. Possibly on this account Sir James 
Young Simpson (1811-1870) of Edinburgh, Scotland, endeavored to find a 
substitute. It is unanimously agreed that a chemist of Liverpool, England, 
by the name of Waldie, suggested chloroform to Simpson. Simpson experi- 
mented with this drug on himself and others at his residence, with successful 
results, November 4, 1847. The first surgical operation made under the 
influence of chloroform was performed at Edinburgh, November 15, 1847. 

The Field of Application of Anesthetics. — At the present time general 
anesthesia is not limited to surgical operations, where it plays the important 
part in relieving pain, abolishing consciousness, and obliterating psychical 
effects on the patient, but its use is extended to other realms. In the diagnosis 
of obscure abdominal and pelvic conditions the aid of an anesthetic is fre- 
quently required to permit a more thorough examination. Anesthesia plays 
an important part as a means of differentiating between a true ankylosis or 
an assumed stiffness of a joint in that class of individuals who are anxiously 
awaiting an opportunity to demand remuneration for some supposed damage. 



Mixed Anesthesia 267 

Frequently by this means the surgeon is able to distinguish the malingerer 
from the honest claimant. Anesthesia is advisable in the reduction of frac- 
tures and dislocations to relax muscular tension and permit a more thorough 
manipulation of the injured member. The differential diagnosis between 
hysteria and organic lesions of the brain and cord may be made by adminis- 
tering a sufficient amount of anesthetic to produce partial unconsciousness. 
In obstetric practice it certainly is a blessing to the prospective mother. 

Mixed Anesthesia. — By this term is understood the hypodermatic admin- 
istration of narcotic drugs, such as morphin, atropin, hyoscin (scopolamin), 
or a combination of morphin with either of the other drugs an hour or two 
previous to the administration of a general anesthetic. (See sections in this 
lecture on "Anesthetic Mixtures" and "Anesthetics in Sequence.") The 
philosophy of the use of these narcotics has been briefly mentioned in the 
lecture on the "Preparation of Patient for Operation." Some surgeons dis- 
pense with the use of these drugs as a pre-anesthetic measure because of 
certain disadvantages they claim follow their use ; as excessive depression is 
developed, anesthetic stupor prolonged, body-temperature lowered, the lia- 
bility of respiratory failure increased, etc. These operators fail to comprehend 
that by the use of these drugs advantages are obtained which more than offset 
their disadvantages, besides the objectionable effects, if any, are due in most 
cases to faulty technic in administering the anesthetic. But even the most 
ardent advocates of mixed anesthesia did not grasp the far reaching and 
beneficial effects produced by these drugs until Dr. Geo. W. Crile demon- 
strated in his usual scientific and convincing manner that certain changes 
were produced in the cerebral cells of a patient by psychic effects endured 
previous to operative interference and traumatic impressions suffered during 
an operation* The changes which occurred in the brain-cells from these 
two causes so lowered or reduced the vital force of the subject as to increase 
surgical risk. One of the most prominent psychic factors which induces such 
changes in the cerebral-cells is fear with its concomitant emotional disturb- 
ances. "Fear is stronger than the will," as Crile tersely states it. Regardless 
of efforts at self-control, fear unchecked and untrammeled develops under 
certain conditions, until such deleterious changes are made in the brain-cells 
as to permit of their eliminating nervous energy to an abnormal extent. The 
patient is thus handicapped before a step is taken in the surgical ordeal. The 
amount of fear which develops in patients of course depends on individuality. 
The subject with a naturally susceptible temperament, impressionable nature, 
and imaginative mind becomes an easier prey to fear, and the changes 
wrought in the cerebral-cells in such patients will be proportionately greater 

* The reader is referred to an article written by Dr. Crile (Journal American Medical 
Association, Dec. 2, 1911), "Newer Methods for Further Increasing the Safety of 
Surgical Operations." 



268 Local Anesthetics 

than in those of an opposite temperament. By the use of narcotics adminis- 
tered as a pre-anesthetic measure, the subject is placed in a quiescent state, 
irritating psychic effects are abolished, and thus the cerebral centers are pro- 
tected and the vital force of the patient conserved. In other words the surgi- 
cal risk is diminished. 

Dosage. — The amount of morphin and hyoscin (scopolamin) or other com- 
bination narcotics which should be administered as a pre-anesthetic step must 
correspond with the temperament and physical condition of the patient. This 
is an essential that is frequently overlooked. The common practice of order- 
ing a routine amount for every case should not be countenanced. For 
instance, the impoverished anemic woman will be sufficiently fortified by 
morphin gr. 1/8 and hyoscin (scopolamin) gr. 1/200, while the full-blooded 
and muscular man would require double this amount to produce similar 
effects. Furthermore, it is often advisable to divide the maximum dose which 
is to be given into fractional doses administered hourly, that is to say, if 
morphin gr. 1/4 and hyoscin (scopolamin) gr. 1/100 is the amount consid- 
ered necessary to place the patient in a quiescent state, I am convinced that a 
better effect is obtained by giving morphin gr. 1/8 and hyoscin (scopolamin) 
gr. 1/200 two hours before the time set for operation, and a similar dose an 
hour before the patient is sent to the surgery. By this means a longer interval 
of cerebral-rest is obtained than if the whole amount was injected two hours 
previous to operative interference, because at the end of this period the 
physiologic action of the drug would be passing off and fear would increase 
proportionately as the anticipated time approached. If the total amount were 
injected an hour before the anticipated operation the cerebral-cells would be 
fatigued up to the time the injection is administered. A very short interval 
of brain rest is thus given. While the number of cases in which I have used 
this fractional method in my clinic is limited, both my anesthetist and I feel 
that a progressive step has been made. 

Local Anesthetics Employed Contemporaneously with General Anes- 
thetics. — When the patient is under normal surgical anesthesia produced by 
ether or chloroform sensibility to pain of course is abolished, but the cerebral- 
cells are only diminished or obtunded in their activities, and are capable of 
receiving and recording external stimuli. Crile demonstrated that the effects 
of traumatism incident to surgical operations were carried to the brain-cells 
and produced such changes in them as to reduce vital force and thus further 
handicap the patient. To prevent these impressions from reaching the brain, 
dilute solutions of local anesthetics are injected either in the field of operation 
or in the nerve supplying the area of surgical interference. The nerve end- 
ings being thus anesthetized, impressions which would be carried to the 
brain-cells are blocked, and the vital force in this way conserved. Besides 



Local Anesthetics 269 

which, a smaller amount of the general anesthetic is required, which is an- 
other item in the conservation of the patient's resistance. 

When nitrous oxid-oxygen is the anesthetic employed the condition is 
somewhat changed. The cerebral-cells depend for their functionating ability 
on a normal amount of oxygen. Inasmuch as nitrous oxid displaces the nor- 
mal amount of oxygen, the brain-cells are inhibited in their function in 
proportion to the deficiency of oxygen. Receptive impressions are therefore 




Illustration LVIa 

Method of administering- a Local Anesthetic. Observe the syringe is 
held parallel with the part to be anesthetized and the needle pene- 
trates the skin only, not the subcutaneous tissues. Note the wheal 
produced by the infiltration of the solution as is shown by the 
white line on the surface. The needle employed should be long 
and fine. The usual steps in sterilization must be made before 
infiltrating the anesthetic solution. Compare this technic with the 
hypodermatic administration of morphin, etc., as seen in illustra- 
tion XVIa. 



minimized and the dischargeable nervous energy from the nerve-cells cur- 
tailed. Hence by the use of nitrous oxid-oxygen the brain-cells are protected 
to a greater or less extent from the traumatism of the operation, and the vital 
force of the patient proportionately increased. The combination of nitrous 
oxid and oxygen, however, permits the cerebral-cells to retain some oxygen 
within themselves and hence some impressions do reach the centers. To off- 



270 Anesthetic Mixtures 

set which local anesthetics are utilized in the field of operation to block any 
impulses that may be received by the partially incapacitated cerebral-cells. 
The physiologic effects of nitrous oxid and oxygen are very transient, so that 
the employment of local anesthetics also dulls the sharp edge of pain in the 
operative field after surgical interference. 

Local Anesthetics Commonly Used — Strength of Solution. — Novocain or 
cocain are certainly preferable to any others, and are generally used in a one- 
fifth- to one-fourth-per cent, solution. The suggestion which has been made 
of using quinin and urea hydrochlorid as a substitute for the above drugs be- 
cause of its long lasting anesthetic effects may prove worthy of trial in dilute 
solution (one-eighth to one-fourth per cent.), but the experience of the writer 
with the use of this anesthetic in minor operations, such as amputations of 
the digits, or any location where the skin is involved, prohibits his recom- 
mending it for this purpose, because of the slough which follows the injec- 
tion of a onc-per cent, solution. These solutions should always be made with 
sterile normal saline solution, and not plain sterile water. 

Anesthetic Mixtures. — By this term is understood combinations or mix- 
tures of chloroform, ether, and other drugs. At the present time their use is 
very limited, and practically dispensed with in this country. Among such 
combinations may be mentioned the A. C. E. mixture, the formula of which 
is as follows : 

Alcohol one part ] 

Chloroform two parts vby volume 

Ether three parts J 

The C. E. Mixture : 



Chloroform two parts ) , , 

> by volume 



Ether three parts 

I have mentioned these combinations simply to complete the text of the 
subject; they are not recommended. 

Anesthetics Administered in Sequence. — Under certain conditions it 
occasionally is beneficial to start w T ith one anesthetic, and subsequently change 
to another drug to maintain and complete the anesthesia; this is known as 
anesthetics in sequence. 

Various conditions may arise which make this method of producing anes- 
thesia appropriate, as in cases of alcoholics, or in those patients addicted to 
drug habits who are prone to be excitable and difficult to bring under the in- 
fluence of the anesthetic of choice. In such cases chloroform is generally 
employed until unconsciousness is obtained, followed by some other 
anesthetic. 



Preparation of the Patient 271 

The irritating effects of ether on the respiratory mucous membrane when 
first administered make it advisable frequently to utilize chloroform at first 
to be followed by the administration of ether ; or nitrous oxid may be substi- 
tuted for chloroform. 

When nitrous oxid-oxygen has been selected as the anesthetic a small 
amount of ether may be added during the administration of the gas to over- 
come some deficiency in the effects of the nitrous oxid, after which ether is 
stopped and the nitrous oxid-oxygen anesthetic continued alone. Tech- 
nically this is really an anesthetic mixture, because there has been no inter- 
ruption of the nitrous oxid-oxygen administration, but simply an addition 
of a small amount of ether. The more expert the anesthetist becomes in the 
administration of nitrous oxid-oxygen, the less use will there be of ether. 

Preparation of the Patient. — A systematic preparation of the patient who 
is about to be anesthetized is only another of the many modern refinements, 
I should say safeguards, which have been added to the technic of surgical 
procedures. The well educated and conscientious surgeon before advising 
his patient to submit to a surgical operation, takes into account not only the 
disease for which he is consulted, but carefully investigates the general 
physical condition of the patient. He immediately decides by this examina- 
tion if the patient is capable of withstanding surgical interference and its 
concomitant anesthesia. If his opinion is favorable for an operation, the 
physical examination becomes really the first step in the preparation of the 
patient for an anesthetic. In well-regulated hospitals further examinations 
are made the day previous to an operation to confirm the physical condition 
of the patient. The diet is regulated ; the drinking of large quantities of 
water encouraged, and efforts are made to stimulate the excretory organs of 
the body to their full capacity, besides paying attention to the toilet of the 
mouth, — the reasons for all of which have been detailed in my lecture on the 
"Preparation of Patient for Operation/' The clinical laboratory at the 
present time has become a necessity to the modern surgeon. This department 
makes the chemical and microscopical examinations of the urine, from which 
deductions are made as to the functionating capacity of the kidney and occa- 
sionally reveals the presence of diabetes, or some other abnormality which 
was not suspected. It also furnishes the report of the blood examination, 
from which the surgeon ascertains the amount of natural resistance the 
patient possesses ; besides it indicates if destructive changes have been pro- 
duced in the blood by the disease from which the patient suffers ; a record of 
the blood-pressure is made and affords knowledge as to any degenerative 
changes occurring in the heart and blood-vessels ; — all of which directly or 
indirectly play a part in the preparatory treatment of a patient for an anes- 



272 Preparation of the Patient 

thetic. Moreover the choice of an anesthetic is frequently determined by 
the clinical reports of the condition of the kidney, the amount of blood- 
pressure, and the result of the blood-examination. 

In order to emphasize the preparation a patient should receive previous to 
being anesthetized I take the liberty of repeating, not only the suggestions 
given in this lecture, but also referring to such steps as bear on this subject 
in the lecture on the "Preparation of Patient for Operation." 

A thorough physical examination of the patient is imperative. 

On the day previous to operation the following routine is carried out : 

(1) Clinical laboratory reports are made of the urine, blood, blood- 
pressure, etc., to confirm the physical examination. 

(2) A properly selected diet is chosen. The administration of food should 
cease six hours before the time set for operation. 

(3) The patient is encouraged to drink large volumes of water as a 
urinary stimulant, which should be discontinued at least three hours before 
the administration of the anesthetic. 

(4) Properly selected cathartics are administered to relieve the bowel of 
fecal accumulations. 

(5) The cleansing of the patient's mouth and teeth is accomplished by the 
frequent use of the ordinary toothbrush and some alkaline antiseptic wash to 
remove infectious debris which may be inhaled during the administration of 
the anesthetic, and in operations on the stomach it lessens the liability of 
infection from this source. This toilet should be repeated just before the 
patient is taken to the operating-room. 

On the day of the operation the following is the schedule : 

(1) Rectal enemata are usually administered four hours previous to the 
time set for operation. 

(2) A hypodermatic injection of morphin-atropin or morphin-hyoscin is 
given a half hour to two hours previous to the administration of the anes- 
thetic. (Some surgeons use the former combination, others employ the latter 
formula, while a third class of operators dispense with these drugs 
altogether.) 

(3) Before being taken to the operating-room the patient is either per- 
mitted to empty the bladder, or if necessary catheterized. 

(4) As a final step remove all artificial plates of teeth — the nurse takes 
care of these. Some anesthetists prefer allowing a patient who wears a com- 
plete upper and lower plate to retain them in place during the anesthetic, 
claiming a freer respiration is thus afforded and that the size of the plates 
prevent them from being swallowed. The nurse should know the anes- 
thetist's views on the subject. 



Modifications in Preparation of Patient 273 

Modifications in the Preparation of the Patient — Emergencies. — In my 

lecture on "The Emergency Operating-room" I have outlined the manner in 
which the sufferer's clothing is removed and the hospital gown substituted. 
In this class of cases time is an important element. Nevertheless, it is im- 
perative to ascertain the condition of the patient's lungs, heart, and blood- 
vessels. Gastric lavage is indicated, unless a penetrating wound of the 
stomach is suspected, under which circumstances it is omitted. In accident 
cases where hemorrhage has depleted the patient, or shock is present, no time 
is to be lost in this preparatory step. These complications should be imme- 
diately met by transfusion, which is the only preparatory measure that 
insures safety to the patient from the further depressing effects of the anes- 
thetic and operative measures. Transfusion in these cases becomes a lever by 
which defeat is changed into victory and a state of dissolution transformed 
into one of natural resistance. Since Crile demonstrated the increased body- 
resistance which can be obtained by transfusion in such cases, every advanced 
surgeon has confirmed his views by his own clinical experience. Emergency 
patients who are totally unfit to receive an anesthetic and undergo an opera- 
tion are thus rendered practically immune against the deleterious effects of 
the drug and the harassing effects of the necessary operation. Leonard Hill 
demonstrated that when the blood-supply to the central nervous system is 
below par chloroform (as well as other narcotic poisons) affect the centers 
of vitality more readily; that the ordinary amount of anesthetic which can be 
administered when the blood-pressure is normal, will prove fatal in a blood- 
pressure which has declined. Moreover the whole vascular system becomes 
so affected that the blood drains from the arterial system into the large 
abdominal veins. This statement, emanating from such an authority as Hill, 
in conjunction with Crile's demonstrations, should be prima facie evidence 
of the necessity of transfusion as a preparatory measure to anesthesia in 
emergency cases suffering from shock or hemorrhage. 

The administration of strychnin, digitalis, etc., plays a very minor part as 
a stimulant under these conditions. The transient stimulating action of an 
intravenous infusion of normal saline with adrenalin chlorid is a poor pre- 
anesthetic measure as compared with transfusion for the unfortunate class 
of whom we are speaking. Nevertheless circumstances may compel its use. 
(See lectures on "Surgical Shock" and "Transfusion — Infusion.") More- 
over, Crile has demonstrated that transfusion is the preparatory measure to 
be instituted on those patients whose general health has been so undermined 
by disease as to render them unfit subjects for an anesthetic and its con- 
comitant operation. Therefore transfusion should be recognized as a neces- 



274 The Anesthetizing-room 

sary step in the preparation of the patient for an anesthetic whose vitality 
has been suddenly reduced by an emergency, or whose resisting power has 
been depleted by disease. 

The Anesthetizing-room. — This room should be light, cheerful, and kept 
to the highest standard of cleanliness. Everything should be prepared and 
in its place so as to impress the patient with the orderly manner in which 
details are carried out. It should communicate with the operating-room by a 
large doorless opening to facilitate moving the patient to the surgery when 
anesthetized. (See illustration LVI.) The furniture should be of the sim- 
plest kind and consist of such articles as are necessary. The following is the 
equipment : 

(1) An ordinary wheel car or stretcher for transporting patients from 
their room to the anesthetizing-room. 

(2) An anesthetizing-stand similar to the one used in the operating-room, 
equipped with the following (when in use) — 

(a) Anesthetics (ether and chloroform). 

(b) Tongue forceps. 

(c) Mouth-gag. 

(d) Inhalers and cones which are cleansed and sterilised after each 

administration. 

(e) Hypodermic syringe equipped and filled with some heart stimulant. 

(f) An atomizer filled with a solution of cocain (4 per cent.). 

(g) Face demulcent. 

(h) Sterile rubber dam to protect the patient's eyes, 
(i) Anesthetic charts, 
(j) Sterile towels, 
(k) Pus basin. 

(3) One complete apparatus for the administration of nitrous oxid and 
oxygen, together with extra tanks of these gases.* 

(4) One aseptic cupboard in which are stored ether, chloroform, etc., 
anesthetic charts, cones, inhalers, sphygmomanometer, and such other articles 
as come under the supervision of the anesthetist. This cupboard should be 
kept locked. 

(5) One metallic stool for the anesthetist. 

(6) One metallic closet with perforated shelves, heated either by steam 
or the more modern electrical warmer. The blankets and gowns for pa- 
tients' use after operations are stored in this. 



* When nitrous oxid-oxygen is employed, the patient is anesthetized in the operating- 
room and this apparatus is removed to the surgery. 



The Anesthetist — Statistics 275 

The Anesthetist. — Self-confidence is a characteristic that every anesthetist 
should cultivate. While sympathy and kindness are necessary attributes, 
there should be that firmness and decision of character which will impress 
the patient that the anesthetist is perfectly familiar with the necessary 
details. 

The toilet of the anesthetist should be as esthetic as the duties to be per- 
formed will permit. Proper uniforms and headcovering should be assumed 
and possibly a face mask, if this is required by the surgeon. Attention 
should be paid to the cleansing of the hands and manicuring of the nails. 
In operations on the face and within the cranium the anesthetist should make 
a sterile toilet and endeavor to maintain it during operative procedures in 
order to prevent contamination of the field. The anesthetist should be pro- 
vided with a watch to accurately record the pulse and respiration, the watch 
should be located where it can easily be seen to make the necessary observa- 
tions. Occasionally as in cranial or hazardous operations, the sphygmoman- 
ometer is utilized to determine the patient's blood-pressure during the sur- 
gical procedure. To observe the readings of this instrument an assistant is 
designated especially for this purpose. 

Statistics. — Chloroform, Ether, and Nitrous Oxid-oxygen are the only 
anesthetics I shall call to your attention because I believe they are the only 
drugs known at the present time worthy of consideration in this special field. 
I desire to impress on you that the ideal anesthetic has not been discovered. 
Since Morton demonstrated the efficacy of ether as an anesthetic the pro- 
fession has been endeavoring to find some drug or combination of drugs 
which would fill the necessary requirements for anesthesia without the dis- 
advantages which all our modern anesthetics possess to a greater or less 
extent; so far with negative results. All anesthetics have to their credit a 
certain death-rate. Correct statistics cannot be obtained as to the mortality 
attached to the three drugs of which we are speaking, because the dangers 
accruing to a patient under the influence of an anesthetic depend to a great 
extent on the experience and personal equation of the anesthetist. By this 
I mean not only the deaths that immediately occur when the subject is under 
anesthesia, but the injurious effects which play a greater or less part in the 
deaths occurring later. In order to give you an approximate idea as to the 
fatalities connected with chloroform, ether, and nitrous oxid I shall cite Dr. 
Hobart A. Hare's statistics as given in Keen's Surgery : 

Chloroform. . . .one death in 2,500 anesthetics 

Ether one death in 16,000 anesthetics 

Nitrous Oxid . . one death in 200,000 anesthetics 



276 Chloroform — Circulatory System 

Statistics vary with different authorities, but the foregoing I think are suf- 
ficiently correct for our purpose. They portray to the mind at least the 
relative dangers of each of the drugs. 

Chloroform — Physical and Chemical Properties. — Chloroform is a clear, 
colorless, heavy fluid with a specific gravity ranging between 1.490 and 1.497 
at 62.5 °F. It possesses a characteristic odor. Its vapor is not inflammable, 
but in the presence of an open fire the vapor is decomposed, forming fumes 
which are exceedingly irritating to the respiratory tract. (See lecture on 
"Major Surgery in Private Practice," section "Preparation of the Extem- 
porized Operating-room.") It is easily decomposed by heat and light, and 
hence should be kept in a cool room in small dark-colored containers. The 
common practice of purchasing this drug in one-pound bottles and using 
therefrom as necessity demands is wrong. When chloroform is evaporated 
on a watch glass no residue or odor of the drug should remain. It is a power- 
ful solvent for fats. The reaction of this drug should be neutral to litmus 
paper. 

The Effects Produced by the Inhalation of Chloroform — The Cerebro- 
spinal Nervous System. — The action of chloroform on this system depends 
on the amount of the drug inhaled. The activity, sensibility, and motility of 
the different portions of the cerebro-spinal system are decreased, obtunded, 
or diminished in the following sequence. 

(1) Perceptive centers in the posterior cerebral convolutions. 

(2) The intellectual centers in the anterior or frontal convolutions. 

(3) Motor areas of the cortex. 

(4) Sensory tracts in the cord. 

(5) Sensory portions in the medulla. 

(6) Motor portions of the cord and medulla. — Hobart A. Hare. 

When these latter motor portions are affected the amount of anesthetic 
administered is far in excess of that which is necessary for surgical anes- 
thesia. Further administration of the drug will entirely obliterate the vital 
centers located in the medulla. 

Heart and Circulatory System. — From the anesthetist's standpoint the 
effects of chloroform on this system are of paramount importance. This 
drug produces a direct depressant action on the heart muscle, resulting in the 
loss of its expulsive force, and sooner or later causing dilatation. Its effect 
on the vasomotor center is one of depression. The normal control possessed 
by this center on the vasomotor nerves which regulate the caliber of the 
blood-vessels is therefore handicapped. A relaxation of the entire vascular 
system occurs and results in lowered blood-pressure. The coronary arteries 
which supply the heart muscle with nutrition and stimulation suffer in pro- 
portion to this reduction in blood-pressure. The consequence is, the amount 



Chloroform — Respiratory System 277 

of blood carried by these vessels is not sufficient to maintain cardiac 
physiology, so that the heart is suffering from the direct effects of the drug, 
plus a lack of nutrition and stimulation. If the administration of chloroform 
is carried to an unnecessary extent the circulation is still further impov- 
erished by a greater reduction of blood-pressure — the result of the exhaust- 
ing effects on the vasomotor center, and a condition is developed that 
simulates one of surgical shock. 

The Respiratory System. — One of the necessary requirements for any or- 
gan to possess, in order for it to perform its function physiologically, is a 
normal circulation. This is especially true of the vital centers. When the 
blood-current has been reduced in volume and its pressure decreased to an 
abnormal point from the effects of chloroform, the respiratory center suffers 
because of the subnormal circulation. The consequence is the respirations 
become weaker and more shallow, and sooner or later give evidence of fail- 
ure. If administration of the drug is continued paralysis of the respiratory 
center follows — the result of decreased blood-pressure. Thus it can be seen 
that the effect of chloroform on the respiratory apparatus is secondary to its 
effect on the circulatory system; furthermore, if close attention is paid to the 
respiration of a patient under the influence of this drug, deductions can be 
made as to the condition of the circulation. While the effect of chloroform 
is irritating to the mucous lining of the respiratory tract, it is by no means 
as much so as ether. 

The sudden deaths which are occasionally witnessed during the adminis- 
tration of chloroform, can be attributed to a heart whose musculature is 
handicapped by some preexisting degenerative process, and which only needs 
the depressing influence of the anesthetic to produce a fatality. 

Sudden deaths may also occur immediately the administration of chloro- 
form is begun, and before a sufficient amount has been inhaled to produce 
any depressing effects. There are three factors I think responsible for this 
accident — 

(1) Intense fear of the anesthetic on the part of the patient. 

(2) A reflex action causing cardiac inhibition, the result of vagus 
irritation. 

(3) A degenerative process in the heart muscle. 

The Blood. — Chloroform has been shown by DaCosta and others to pro- 
duce changes in the blood. Destruction occurs in the red blood-corpuscles, 
their shape is changed and hemoglobin diminished, and hence anemia is 
produced. The temperature of the body is lowered, and the natural resist- 
ance of the economy reduced. 



278 Chloroform — Indications and Contraindications 

The Kidneys. — The action of this drug on these organs is to cause irrita- 
tion. The amount of chloroform necessary to produce surgical anesthesia, 
however, should be insufficient to cause deleterious effects. 

The Liver. — Chloroform is supposed to have a selective action on the 
hepatic structure ; causing degenerative changes similar to those seen in acute 
atrophy, while other observers report a condition of fatty degeneration as 
the result of chloroform anesthesia. 

The Skin. — Chloroform acts as an irritant to the epidermis : this should 
always be borne in mind during its administration. 

Indications and Contraindications for the Use of Chloroform. — This drug 
should not be used when there is degenerative changes in the heart muscle. 
In cardiac dilatation and valvular disease of the heart chloroform should not 
be employed unless compensation has been thoroughly restored. When the 
circulation is weak the depressant action of this drug certainly eliminates it 
as the anesthetic of choice. In arterial sclerosis, with its accompanying 
increased blood-pressure (providing cardiac compensation is established), or 
where aneurism is present, chloroform is used. In the respiratory tract in 
the presence of chronic bronchitis, pulmonary abscess, tuberculosis, and in 
some cases of emphysema and asthma, this drug is utilized because it is less 
irritating to the mucous membrane. When pronounced emphysema or 
chronic asthma has been present for a sufficient time to dilate and weaken the 
muscular structure of the heart, the choice between chloroform and ether is 
a difficult problem to solve ; no fixed rules can be given. In operations on the 
throat and mouth, especially in children, chloroform by general consent is 
the anesthetic most frequently utilized, but the flat recumbent position must 
be maintained. In cases requiring the use of the cautery chloroform is 
preferable to ether because of the imminent danger of an explosion occurring 
from the ether fumes. In operations on the kidney, or in other operations 
in which there is present degenerative processes in the structure of the kid- 
ney, especially in acute nephritis, chloroform is indicated because it is less 
irritating than ether on these structures volume for volume. In anemic and 
debilitated patients, or in cases suffering from a general infection, the use 
of chloroform is contraindicated. In the numerous industrial accidents 
accompanied with shock or severe hemorrhage, as well as in operations which 
will consume a long period of time and in which shock or hemorrhage is 
anticipated, chloroform has no claim as an anesthetic. In obstetric practice 
it is universally used, excepting, possibly, what may be termed surgical 
obstetrics. Chloroform is contraindicated as an anesthetic in diseases of 
the liver. 



Chloroform-ether Anesthetic Slip 



279 



The Administration of Chloroform. — The following anesthetic form as 
will readily be seen is gradually compiled. Such forms impart valuable in- 
formation, not only during the operation and immediately afterwards, but 
statistics gathered from properly kept anesthetic slips are of the greatest 
benefit for future reference. They also serve as evidence in medico-legal 
questions as to the care or lack of care a patient received during the adminis- 
tration of the anesthetic. 

Chloroform-ether Anesthetic Slip. — 

Name of patient 

Room number 

Anesthetic used 

Pulse Respiration (Before anesthesia) 

Anesthetic started 

Anesthetic completed 

Operation started 



TIME 


PULSE 


RESP. 


TIME 


PULSE 


RESP. 































































Anesthetic ended 

Operation ended 

Pulse Respiration. 

Amount of oxygen used 

Amount of anesthetic used. . . 
Hypodermic medication used. 

Saline infusion Amount 

Packing or drainage used .... 
Character of the operation. . 



(After operation) 



.How employed 
.Where 



Anesthetist 
Date 



280 



Chloroform — Preliminary Steps 



Preliminary Steps. — 

The place of administration — anesthetizing-room. 

Choice of location — operating-table. 

Posture — flat recumbent, head slightly lowered. 

(1) Observe if the patient is sufficiently covered to maintain body- 
temperature. 

(2) Ascertain if false teeth have been removed, or if any foreign body is 
in the mouth. 

(3) Cocainize nares and pharynx to prevent irritation of the nerve end- 
ings of the upper respiratory tract by the anesthetic. 

(4) Apply demulcent to the face to prevent irritation from the drug. 

(5) Instruct the patient to breathe naturally, and under no circumstances 
follow the common practice of suggesting to the patient to take deep inspira- 




Illustration LVII 

An FJsmarch Inhaler. — Thin flannel, stockinet, or gauze is 
stretched over the wire frame and held in position by 
the wire clamp shown in the illustration. 



tions, as in this way an excessive dose of the anesthetic will be inhaled; such 
deep inspirations, together with the unnecessary amount of the drug inhaled, 
irritate the nerve-endings of the upper respiratory tract and tend to produce 
inhibition of the cardiac and respiratory systems. 

(6) Protect the eyes of the patient by a piece of rubber dam or folded 
towel. Explain to the patient the reason for such a step. 

(7) After the intellectual centers are sufficiently obtunded secure the 
patient's hands by the method usually employed, not before this stage is 
reached, because it has a tendency to produce fear and opposition on the part 
of the subject. 

The Inhaler. — The Esmarch is the simplest form of inhaler and consists 
of a wire frame over which is stretched a layer of thin flannel or stockinet. 



Chloroform Container — Inhalation 281 

(See illustration LVII.) It has been demonstrated that the coarser the 
weave of the material which covers the inhaler the more rapid is the evap- 
oration and the greater is the dose of the drug received by the patient, — a 
point to be remembered. In private practice a folded handkerchief or 
napkin is frequently used as a substitute for the inhaler. Another simple 
form of inhaler is seen in illustration LVIII. 

The Chloroform Container. — Any ordinary bottle with a stopper which 
will permit a gradual dropping of the drug is all that is necessary. Another 
simple means of facilitating the administration of the drug by the drop 



--:■ 




Illustration LVIII 

An excellent inhaler. It is prepared for use in the 
same manner as the Esmarch Inhaler. 



method is afforded by cutting a V shape channel in the cork of the chloro- 
form container and inserting into this groove a wick of twisted absorbent 
cotton or gauze. 

The Inhalation. — 

(1) Hold the inhaler one-half inch from the face. 

(2) Drop the chloroform at the rate of eighteen to twenty drops per 
minute on the inhaler. This will give about a one- to one and one-half per 
cent, mixture of chloroform. 

(3) Observe the respirations by watching the respiratory action of the 
thorax and listen to the force of expiration. Note the rate and character of 
the pulse by palpation of the temporal or facial arteries ; if this latter vessel 
is utilized for this purpose as it passes under the angle of the lower jaw the 
palpating hand can also hold this member upward and forward, and thus 
permit a free access of air. During surgical anesthesia when muscular re- 



282 



Normal Surgical Anesthesia 



laxation is present the head has a tendency to fall forward and thus con- 
strict the larynx. 

(4) If the respirations continue smooth and their rhythm normal, the 
inhaler may be slightly lozvered on the face, thus gradually concentrating the 
chloroform vapor, but still permitting a free access of air. Approximately 
this will afford a two-per cent, mixture of chloroform, which is the max- 
imum mixture to be inhaled. 

(5) Pay close attention to the pupils, which at the beginning of the admin- 
istration of the anesthetic are somewhat dilated, but as the anesthetic state 
is approached contraction of the pupillary orifices occurs. A sudden dilata- 
tion of the pupil at this stage is an indication of impending danger. 

(6) Carefully note the color of the face, ears, and lips. The patient's 
normal color should always be maintained, any tendency toward cyanosis is 
at once an indication for the cessation of the anesthetic. 

No adverse symptoms arising, the patient will be anesthetized in about 
ten minutes. 

Signs of Normal Surgical Anesthesia. — The respirations are regular and 
quiet. The pulse is full and the rate possibly slower than when the anes- 
thetic began because excitement is abolished. The color of the face is that 
which is peculiar to the patient, but under no condition cyanotic. The pupil 
of the eye is somewhat contracted, the lid-reflex abolished. The muscles are 
relaxed so that if the arm of the patient is raised from the table it falls 
helplessly. 

After complete anesthesia has been obtained it is frequently possible for 
the anesthetist to reduce the amount of chloroform, either by decreasing the 
number of drops per minute, or by raising the mask and causing a greater 
dilution of the drug. 

Untoward Conditions. — If however respiratory spasms occur at the begin- 
ning of the administration of the drug remove the inhaler from the face and 
allow the patient to have a breath or two of fresh air, then continue as before. 
If the patient becomes pugnacious and struggles, the anesthetic should be 
immediately suspended until struggling ceases. It is in these cases the unin- 
itiated makes the fatal error of attempting to subdue the patient by increasing 
the amount of chloroform. It can easily be understood that during such 
struggles the inspirations are increased in frequency and depth, and hence 
even though the amount of chloroform is not increased the amount inhaled is 
greatly in excess of what is needed. Added to this is the extra work which 



Chloroform Anesthesia Accidents 283 

is thrown on the heart during this period of excitement and the depressing 
influence of the drug on this organ, — a combination conducive to a fatality. 

Accidents Occurring During Chloroform Anesthesia. — Circulatory failure 
is the most frequent accident encountered. This may occur in three ways : 

(1) The direct depressant and degenerative action of the drug especially 
on a heart whose musculature is handicapped by some preexisting degenera- 
tive process. A fatality may ensue under such conditions when the anesthetic 
is safely within therapeutic dosage. 

(2) Cardiac inhibition produced through irritation of the vagus, especially 
if associated with a diseased myocardium. In this case also the amount of 
drug administered may be within the bounds of safety in a subject with a 
normal heart, but on account of the degenerative condition of the myocar- 
dium the accelerator nerves of the heart cannot overcome the amount of 
inhibition. 

(3) A fatality may occur from a lethal dose of the drug directly affecting 
the heart muscle and vasomotor center, thus producing lowered blood- 
pressure, followed by respiratory failure. 

Symptoms. — Inasmuch as a diseased myocardium is either directly or indi- 
rectly responsible for two of the three ways in which a fatality may occur 
as the result of circulatory failure and the difficulties encountered in the 
diagnosis of many degenerative changes associated with the heart muscle, 
one can easily understand the sudden appearance of alarming symptoms 
when the patient is apparently in a favorable condition. In most cases there 
is not the slightest warning, the pulse, which was strong, regular, and of 
good character immediately before symptoms of circulatory failure appeared, 
becomes rapid, hardly perceptible, and irregular ; the pink color of the face 
changes instantly to one of a dusky cyanotic character, the respirations 
become shallow and gasping, the pupils extremely dilated. When circulatory 
failure is due to a lethal dose of chloroform the symptoms do not make their 
appearance with the same rapidity, but there is more or less of a period of 
gradual circulatory decline, followed of course with a proportionate decrease 
in the respiratory function. 

Treatment. — 

(1) Cardiac inhibition caused by the irritation of the vagus can be pre- 
vented by the administration of pre-anesthetic alkaloids such as morphin and 
hyoscin. Prevention is better than cure. 

(2) Circulatory failure developing, place the patient in the extreme Tren- 
delenberg position if on the operating-table, or in some similar posture if in 



284 Artificial Respiration 

private practice, in an endeavor to maintain a circulation around the cerebral 
centers, as well as to facilitate the emptying of the large abdominal vessels. 

(3) Immediately resort to artificial respiration and the administration of 
oxygen. At the same time massage the heart by pressure and counter- 
pressure over the thorax in rapid succession. This has been demonstrated 
to excite cardiac action. If the operation be a celiotomy the heart may be 
massaged through the diaphragm. 

(4) Laborde's method of pulling the tongue forward and downward and 
then allowing it to fall backward may be tried. These rhythmic movements 
should be performed sixteen to twenty times per minute. 

(5) Intravenous injection of solution adrenalin chlorid 15 to 20 m. should 
immediately be employed. Intramuscular injections of strychnin sulph. gr. 
1/30 may be utilized as well as atropin gr. 1/50; these injections should be 
given in the upper extremity. The administration of nitroglycerin hypoder- 
matically, or the employment by inhalation of amyl nitrite should not be 
countenanced because both of these drugs are vasodilators, and only serve to 
increase the dilatation of the blood-vessels which already exists. 

Artificial Respiration — Sylvesters Method. — This is chiefly applicable to 
women, children, and poorly developed individuals. Where great muscular 
development is present Howard's method is preferable. 

(1) Place the patient flat on the back on the operating-table with the 
head somewhat lower than the chest, so as to extend the throat. 

(2) Pull the tongue slightly forward so as to prevent it falling backward 
and causing obstruction. 

(3) Grasp the arms just above the elbows and firmly compress them 
against the walls of the chest so as to expel any latent anesthetic. 

(4) Have an assistant make upward pressure upon the abdomen below 
the diaphragm so as to increase the intrathoracic pressure caused by step 
three. 

(5) Slowly lift the arms upward and outward at the same time making 
traction until they meet above the head. Pause so as to permit all the air 
possible to enter the lung, then carry the arm to the side of the chest-wall 
and renew the pressure as in the first step. 

The cycle of movements is repeated twelve to sixteen times per minute. 
Howard's Method. — 

(1) Place the patient flat on the back on the operating-table with head 
extended so as to prevent any obstruction to the air passages. 

(2) Extend the arms above the head and retain them in that position. 

(3) Kneel astride the patient. 



Ether — Effects Produced 285 

(4) Place the thumbs on the xiphoid cartilage and apply the hands to the 
chest-wall so as to grasp the free margin of the ribs, thus compressing the 
thorax. 

(5) Lean forward with the whole weight of the body pressed upward and 
inward against the diaphragm for a couple of seconds. 

(6) Suddenly release the pressure by raising erect, thus relieving the 
pressure both from below the diaphragm and from the sides of the chest. 

The cycle of movements is repeated twelve to sixteen times per minute. 

Ether — Physical and Chemical Properties. — Ether is a clear, colorless 
liquid, highly volatile, with a pungent odor and burning taste. Its specific 
gravity should range from 0.720 to 0.713. It boils at 95°F. Its reaction to 
litmus paper should be neutral. It is miscible in alcohol, chloroform, benzin, 
etc., but only slightly so with water. It is very inflammable, and its vapor 
when combined with air explodes violently. According to Buxton "explosion 
has followed when ether was incautiously held near an electric lamp." It 
should never be used in close proximity to a gas jet or an open fire, nor in 
surgical work in which an electric cautery is employed. Ether vapor is 
heavier than air so that Dr. Hobart A. Hare says in this connection, "it falls 
to the floor and is present there in a far more concentrated form than the 
anesthetizer appreciates, and being carried by drafts to a fire in an open grate 

may cause an explosion A number of cases of this character 

have been reported." As ether readily decomposes when exposed to air, 
light, and heat, it should be preserved in small dark-colored bottles well stop- 
pered, or in tin containers, and not stored in a warm room. 

The Effects Produced by the Inhalation of Ether — The Cerebrospinal 
Nervous System. — The immediate action of ether on the brain is one of 
exhilaration, so that all of the cerebral centers for a short time pass through 
a stage of excitement. The patient has fanciful ideas, possibly may be talka- 
tive or pugnacious. These effects are always present, even though they may 
not be in evidence. Very soon the anesthetic effects of the drug become dom- 
inant. The activity, sensibility, and motility of the different portions of the 
cerebro-spinal system are decreased, obtunded, or diminished in the same 
sequence as has been observed from the effects of chloroform, viz. — 

(1) Perceptive centers situated in the posterior convolutions. 

(2) The intellectual centers situated in the anterior or frontal con- 
volutions. 

(3) Motor areas of the cortex. 

(4) Sensory tracts in the cord. 

(5) Motor tracts in the cord. 

(6) The sensory first and then the motor portions of the medulla. 



286 Ether — Heart and Respiratory System 

As has been noted in chloroform a dose sufficient to affect the centers in the 
medulla is far in excess of that which is necessary for surgical anesthesia. 
When the medullary centers are thus affected the gap between life and death 
is limited, because the extreme depressant action of the drug has been 
developed — the amount administered has produced lethal effects. 

The Heart and Circulatory System. — Ether when administered to the point 
of what may be termed normal surgical anesthesia stimulates the heart's 
action and increases its force ; at the same time the vasomotor center is like- 
wise stimulated. With the propelling mechanism (the heart) of the circula- 
tion increased, and the vasomotor center stimulated to a point well within 
the range of what would produce final exhaustion, the blood-pressure is also 
raised. But if the amount of anesthetic is increased beyond that which is 
necessary for surgical anesthesia and maintained at this abnormal point the 
depressing effect of the drug is manifested both on the heart and the vaso- 
motor center, and the result is a lowered blood-pressure. 

The Respiratory System. — The effect of this drug is irritating to the 
mucous membrane of the respiratory tract, producing hyperemia and causing 
an excessive secretion of mucus which at times becomes not only annoying, 
but impedes the administration of the anesthetic. During the early part of 
the administration of the anesthetic the irritant action of the drug is occa- 
sionally manifested on the nerve endings in the upper respiratory tract 
(trigeminus and vagus), producing a temporary inhibition of respiration, or 
spasm of the glottis. This condition may lead the anesthetist to consider the 
possibility of respiratory paralysis. But inasmuch as the physiologic effects 
of ether is a stimulant to the respiratory center and a lethal dose has by no 
means been reached, the incident should hardly cause unnecessary anxiety. 
The respiration at the beginning of etherization is rapid, deep, and ster- 
torous ; when the physiologic effect is obtained it becomes slower, but regu- 
lar. When the anesthetic is pushed to an excess of surgical anesthesia, — in 
other words, beyond the therapeutic point, — the respiratory center becomes 
paralyzed. Respiration generally ceases before cessation of the heart's 
action. 

The Effect on the Blood. — There is somewhat of a discrepancy among 
authors as to the effects of ether on the blood, but the research of Evarts 
Graham undoubtedly is the most careful and scientific that has been under- 
taken. In his exhaustive investigation he concludes, among other things, 
that ether reduces phagocytosis, and that this reduction in phagocytosis is 
due to the action of the drug on the serum and leukocytes, — in other words, 
ether reduces body-resistance. The duration of this lowered resistance de- 



Ether — Indications and Contraindications 287 

pends on the amount of anesthetic administered and the physical condition 
of the patient. Body-temperature is lowered. 

The Effect on the Kidneys. — The action of ether on these organs is to 
cause irritation, possibly not more so than chloroform volume for volume, 
but inasmuch as the amount necessary for surgical anesthesia is greater than 
that of chloroform, the irritating effects are increased. 

The Effect on the Skin. — Ether is an irritant to the skin, producing vesi- 
cation providing a rapid evaporation is prevented. When, however, evap- 
oration is assisted and a sufficient amount of ether used, freezing of the skin 
will be produced. 

The Effect on the Eye. — The local effects on the conjunctiva are very 
irritating. A slight pupillary dilatation is the first change noted from the 
effects of ether, followed by a contraction. A lethal dose of this drug pro- 
duces paralysis of the iris with its accompanying dilatation of the pupil, — a 
point to be remembered. 

Indications and Contraindications for the Use of Ether. — At the present 
time the majority of surgeons, in this country at least, use ether more than 
any other anesthetic. This is accounted for because, however inaccurate the 
mortality statistics may be between this drug and chloroform, it is un- 
doubtedly the safer of the two narcotics. Nitrous oxid-oxygen has a 
mortality twelve to fifteen times less than ether, and but for its deficiencies 
in certain lines (which of late have been practically overcome) and the 
necessity for an anesthetist especially trained in its administration, would 
stand at the head of the general anesthetics. It will eventually, I think, 
occupy a higher position in this field. Ether is indicated in all weakened con- 
ditions of the circulation. In valvular disease of the heart with compensa- 
tion restored, ether is preferable to chloroform, because of its less depressing 
action on the circulatory system. In marked degenerative changes in the 
blood-vessels ether is contraindicated. In spite of the advice of most author- 
ities against the use of ether in surgery of the brain, it is common practice 
among surgeons to use this drug unless very clear contraindications prohibit 
its use. While most books on anesthesia, especially those emanating from 
Great Britain, advise against the use of ether in operations on the thyroid, 
experience in this country demonstrates its practicability. This is easily ac- 
counted for because of the weakened condition of the circulation in such 
patients; but the subject must be properly prepared by pre-anesthetic 
alkaloidal narcotics (mixed anesthesia), and the anesthetic administered by 
an expert. In abdominal and pelvic operations ether has been universally 
used in this country up to the present time, unless such contraindications as 
sclerotic arteries or degenerative changes in the kidneys prohibit its employ- 
ment. In amputations the result of disease or accident ether has always held 



288 Administration of Ether 

a more prominent place than chloroform because of its less depressant 
action. It is self-evident that this anesthetic is better indicated than chloro- 
form where hemorrhage has been excessive or shock is present, both of 
which conditions are common in industrial accidents. Reference has been 
repeatedly made of the contraindication of ether in the various inflammatory 
conditions of the kidney, and is repeated simply to emphasize the fact. This 
drug should not be used in operations within the thorax complicated by 
chronic bronchitis, dilatation of portions of the bronchi, tuberculosis, etc. 
This phase of the question has been considered under chloroform. In 
chronic alcoholics ether may be given in the latter part of the anesthetic, but 
the degenerative changes occurring in the arteries and kidneys of such sub- 
jects must be seriously considered before its employment. On the other 
hand, if chloroform is used at first, great care should be exercised because 
of the depressant action of the drug on the circulation, — a circulation which 
has been weakened by not having its full quota of alcoholic stimulation for 
some hours previous to operation, and in many cases a much longer period 
of abstinence. In acute infections with pronounced constitutional disturb- 
ances ether has no place in the category of anesthetics, because it reduces 
phagocytosis by its action on the serum and leukocytes, as shown by Graham. 
Natural resistance is lowered, and the patient handicapped by the barriers 
of immunity being lessened. 

The Administration of Ether. — The preliminary steps are the same as 
have been described under chloroform, and the anesthetic slip is filled out 
in the same routine manner. There are three ways by which ether may be 
administered: (1) The open method; (2) the semi or partially open 
method, and (3) the close method. "These names are used to designate the 
amount of air limitation the patient receives." I shall only describe the open 
and semiopen methods. 

The Open Method — The Inhaler. — The simple Esmarch inhaler as has 
been described under "Chloroform" is employed. The same should be cov- 
ered by six or eight thicknesses of 14 by 20-mesh gauze so as to afford rapid 
evaporation. 

Ether Container. — This is similar to the one described under chloroform. 
The Inhalation. — 

(1) Hold the inhaler" about one or two inches from the face. 

(2) Drop the ether about twenty to thirty drops per minute, care being 
taken to diffuse the drops over a large surface of the gauze. By this means 
a more thorough admixture of the ether with air occurs. 

(3) Gradually lower the inhaler and increase the frequency of the drops 
so that by the end of ten minutes the mask is practically touching the pa- 



Semi or Partially Open Method 



289 



tient's face, while the frequency of the drop will probably be fifty or sixty 
per minute. Distribute the anesthetic over a large surface of the inhaler. 

(4) After surgical anesthesia is obtained decrease the amount of ether 
to a point sufficient to maintain the anesthetic state ; the amount will vary in 
different individuals. 

The consideration of the patient's respiration and pulse, and the stage of 
excitement which may develop after the first four or five minutes of the 
administration, will be explained when describing the partially open method. 
However, I can do no better than mention here the fact that the so-called 
"stage of excitement" can in most cases be prevented if the patient has been 




Illustration LIX 
An Allis Inhaler. — Showing- the three parts of which it is composed 



properly prepared by pre-anesthetic alkaloidal narcotics, and is not over- 
whelmed from the first by the irritating vapor of the drug which I think is in 
most cases responsible for these untoward exhibitions. The keynote in the 
administration of ether is the gradual increase of the dose until the anesthetic 
state is obtained, then a proportionate decrease to maintain surgical 
anesthesia. 

The Semi or Partially Open Method — The Inhaler. — The simplest form 
of apparatus is that designed by Dr. Allis of Philadelphia, and is the inhaler 
of choice in this country. This can be accounted for not only on the grounds 
of simplicity, but in the hands of the unskilled there is less danger accruing 
to the patient than when a more complicated design is employed ; while the 



290 Ether — The Inhalation 

expert anesthetist is capable of developing and maintaining as tranquil an 
anesthesia as with the more intricate inhalers. It consists of (1) a metallic 
oval jacket open at both ends; (2) a similarly shaped fenestrated cylinder 
which fits within the outer jacket, the depth of this cylinder being about one 
inch less than the outer jacket (the inner cylinder is equipped by means of 
gauze of the proper width and mesh — 14 by 20 — as shown in illustration) ; 
(3) an inflated soft-rubber ring attached to the edge of the outer jacket 
which rests on the face of the patient. This attachment prevents undue pres- 
sure, besides conforming more thoroughly to the irregularities of the face. 




Illustration LIXa 
An assembled Allis Inhaler 

This inhaler can be sterilized by boiling, which of itself merits consideration. 
(See illustration LIX. Illustration LIXa shows the assembled inhaler.) 

The Inhalation. — Dr. A. P. Heineck in his work on General and Local 
Anesthesia makes this epigrammatic statement: "Air slightly impregnated 
-with ether is the first rule, and ether impregnated with air the second." With 
this axiom clearly impressed on your minds, carry out the following steps : 

(1) Place the inhaler over the nose and mouth of the patient. 

(2) Request the patient to breathe naturally, thus demonstrating that 
free respirations can be maintained. 

(3) Begin the administration of ether by slowly dropping the drug 
through the top of the inhaler on a large surface of the absorbing material 
with which the inner cylinder is equipped. 



Ether — The Inhalation 291 

(4) Observe the respirations as carefully at this stage as any other time of 
the administration, as the irritating effects of ether on the nerves of the upper 
respiratory tract during this period may cause spasm of the glottis or 
temporary inhibition of respiration. The respiratory movements at first are 
considerably accelerated and deepened. As the anesthetic state is developed 
these become slower, yet continue deep and regular, but not stertorous ; as 
the lethal dose is approached the respirations become more and more shallow 
until they are gradually extinguished. The character of the respiratory 
movements and the force of the expirations are the signs which should be 
carefully watched. 

(5) Note the character and rate of the pulse by palpation of the temporal 
or facial arteries. If this latter vessel is utilized for this purpose as it passes 
under the angle of the lower jaw, the palpating hand can also hold upward 
and forward this member, and thus permit a free access of air. During 
surgical anesthesia the head has a tendency to fall forward because of the 
relaxation of the muscles and thus constrict the larynx. During the early 
period of the administration of ether anesthesia the pulse is quickened and 
its tension increased. As the anesthetic state is developed the condition of 
the circulation approaches the normal, excepting, possibly, that the arterial 
tension is still somewhat increased. As the lethal dose is approached the 
blood-pressure falls, and the pulse becomes smaller and irregular until 
eventually it is imperceptible. 

(6) If the respiratory movements are free and deep, gradually increase 
the amount of ether until its full physiologic effects are obtained — care being 
taken to diffuse the ether widely over the absorbing surface of the inner 
cylinder. 

(7) Watch the color of the face, ears, and lips; this will be another indi- 
cation as to the condition of the respiratory and circulatory systems. The 
face during the administration of ether should be a bright pink, never 
cyanotic. Occasionally red patches are seen on the neck, chest, and upper 
abdomen, — the so-called "ether rash"; as far as we know these have no 
significance. The skin becomes moist with perspiration as the anesthesia 
progresses. 

(8) Observe the pupil of the eye, which at first is somewhat dilated, 
t>ut as surgical anesthesia is developed gradually assumes a contracted state. 
A sudden dilatation during this stage is an indication of lethal dosage. 

(9) After surgical anesthesia has been obtained reduce the amount of 
anesthetic by decreasing the frequency of the drops, not by withholding the 
drug for several minutes and then swamping the patient with a dram or two 
of ether. Remember the respiratory movement is rhythmical, therefore 
administer the ether rhythmically. The character of the respirations is about 



292 Ether — Untoward Conditions 

as good a guide as one can have in maintaining the required depth of the 
anesthesia. Surgical anesthesia is generally obtained in from eight to fif- 
teen minutes. 

Signs of Normal Surgical Anesthesia. — Among the most prominent may 
be mentioned : 

(1) Loss of consciousness. 

(2) Slow, regular, and deep breathing. 

(3) Muscular relaxation. 

(4) Contracted pupils. 

(5) Lid reflex abolished. 

Untoward Conditions. — With the advent of the skilled anesthetist and the 
modern pre-anesthetic preparation of the patient there has disappeared to a 
very large extent that condition which was formerly encountered in the early 
period of the administration of anesthetics, known as the "stage of excite- 
ment." It must be candidly admitted that the primary effect of ether on the 
brain is one of exhilaration, — the patient has fanciful ideas, possibly may be 
talkative or pugnacious. This effect of the drug can be decreased to a con- 
siderable extent by the administration of morphin-atropin or other narcotic 
alkaloids some time before the anesthetic is begun so as to produce a 
quiescent state of cerebral centers. Moreover the "stage of excitement" 
is frequently the result of improper administration of the drug — the patient 
being literally deluged from the first with ether, instead of having the dose 
gradually increased as tolerance is obtained. The same is true in those cases 
in which spasm of the glottis or inhibition of respiration occurs. These 
complications in the majority of cases will not occur if a proper dilution of 
the ether vapor is permitted during the early administration of the drug. If, 
however, "stage of excitement" is developed, under no consideration follow 
the plan advised by certain anesthetists to increase the dosage and summon 
aid to restrain the patient, because the increased amount of ether vapor will 
produce irritation of the respiratory tract and increase the complexity of the 
administration. The rule should be to withdraw the anesthetic, allow a free 
access of air to the patient, and then gradually increase the ether vapor. 
There are some subjects, and these are a very small minority, in whom it will 
be necessary to obtund the cerebral excitement by first administering chloro- 
form and then resorting to ether. In the last 3,700 etherizations at the 
Protestant Hospital only five per cent, showed signs of the "stage of 
excitement," because the administration of this drug has developed under the 
supervision of Dr. E. C. Ludwig to a point approaching perfection. 

The presence of a large amount of mucus in the throat is not uncommon 
during the administration of ether. The indications are to turn the patient's 



Nitrous Oxid 293 

head to the side and swab the throat and mouth with absorbent cotton 
attached to dressing forceps or a hemostat. This condition, which is very 
irritating both to the surgeon and anesthetist, does not frequently occur if 
atropin is used as a pre-anesthetic measure. Vomiting is simply a sign of 
too light an anesthetic. The vomited material may be inhaled into the 
bronchi and become a serious complication. The indications are met by 
immediately turning the patient's head to the side, removing any accumula- 
tions from the mouth and throat, and then increase the dose of the drug. 

' Accidents Occurring During Ether Anesthesia. — The most serious emer- 
gency which has to be met is respiratory failure, the treatment for which 
will be artificial respiration and Laborde's method of manipulating the 
tongue, in connection with oxygen. Both of these maneuvers have been 
described under "Chloroform." 

Nitrous Oxid — Physical and Chemical Properties. — Nitrous oxid is a 
clear, colorless, practically tasteless, and odorless gas, somewhat heavier than 
air, and with a specific gravity of 1.527. It is neutral to litmus paper. Cold 
water absorbs three-fourths of its bulk of this gas. Nitrous oxid is liquified 
by the use of cold and pressure, in which state it is a colorless and mobile 
fluid. The pressure and temperature necessary to accomplish this being 
fifty atmospheres at 44.6° F. (one atmosphere is the pressure of the air at sea 
level — 14.7 pounds). The gas is marketed in this liquid form in steel 
cylinders of various sizes (100 to 3,500 gallons under 750 lbs. pressure) 
and can be kept indefinitely, as decomposition does not take place unless it is 
exposed to an extremely high temperature. Nevertheless it expands readily 
as the temperature is raised, which should be remembered when storing the 
cylinders. When released from these steel containers it reforms into gas, at 
the same time producing intense cold and the formation of a plug of frost 
which obstructs the valve of the cylinder and interferes with the mixing 
apparatus. The greater the capacity of the steel containers and the larger 
the valve connected thereto the less liable is this to occur, — a point to be 
remembered in selecting the proper size containers, especially for hospital 
use. Nitrous oxid does not support life, yet in the presence of fire an 
increased vigor is obtained in the flame by the liberation of its oxygen. At 
the present moment some hospitals are equipped with facilities for manu- 
facturing nitrous oxid, which reduces its cost to a minimum. After the gas 
is manufactured and washed it is passed into a large gasometer from which 
it is pumped into various sized cylinders ; under such conditions the pressure 
is not carried to a point sufficient to liquify the gas. 

Physiologic Effects Produced by the Inhalation of Nitrous Oxid — The 
Blood. — When inhaled this drug passes through the alveoli of the lungs, 
through the thin walls of the pulmonary capillaries which surround the air 



294 Nitrous Oxid — The Heart 

cells, and thus diffuses itself in the circulation. It is unanimously agreed by 
all investigators that, although a part of the nitrous oxid is dissolved in the 
blood, no chcmlc compounds are formed. According to Buxton the gas "is 
connected in some loose way with the blood constituents, probably being 
associated more or less with the albumins and albuminoids of the liquor 
sanguinis and corpuscles.'' Pickering agrees with the same authority "that 
nitrous oxid is taken into a loose association with the hemoglobin of the 
blood." A reduction of hemoglobin is present after the inhalation of this 
gas, but such reduction is only transient and is seen in all asphyxial states 
however produced. Although there is this loose association or connection 
between this gas and the blood, nitrous oxid displaces the oxygen in the con- 
stituents of this fluid, but this displacement is very evanescent: immediately 
nitrous oxid is withheld and oxygen exhibited, the blood gives up its latent 
nitrous oxid. In other words, the displacement is transient and mechanical, 
and no chemic changes occur. Phagocytosis is not reduced as a result of the 
inhalation of nitrous oxid, nor is disintegration of the red blood-corpuscles 
produced, both of which have a practical bearing when considering its field 
of usefulness. 

The Cerebrospinal Nervous System. — The primary effects of nitrous oxid 
on the higher intellectual centers is one of exhilaration. This condition is 
very rapidly changed to a state of obtunded intellectuality and finally uncon- 
sciousness, with the development of the true anesthetic condition. At this 
time spasmodic contractions of the entire muscular structure of the body 
ensue, undoubtedly due to the de oxygenation of the blood, which is mani- 
fested by pronounced cyanosis. // a correct percentage of oxygen is now 
administered with the nitrous oxid the jactations of the members cease, the 
muscular rigidity is greatly reduced, and the cyanosis disappears. 

Although some authorities claim that anesthesia is produced by a specific 
action of this drug on the cerebro-spinal nervous system, so far they have 
failed to show what the specific action is. I am inclined to think from 
clinical observation that the physiologic action of nitrous oxid on the brain- 
cells is one of inhibition; that is to say, the normal amount of oxygen which 
is necessary for the functionating capacity of the brain-cells is displaced by 
the presence of nitrous oxid, and these cells are inhibited in their function in 
proportion to the amount of this oxygen displacement. In other words, 
anesthesia produced by this gas is simply mechanical, — mechanical anoxemia. 
This phase of the question cannot be further discussed in a lecture of this 
character. (See section "Local Anesthetics Employed Contemporaneously 
with General Anesthetics.") 

The Heart and Circulatory System. — Nitrous oxid is primarily a heart 
stimulant. Its action on the vasomotor center is stimulating to the extent 



The Respiratory System 295 

that blood-pressure is increased and maintained so that animals under the 
influence of this gas (in combination with the proper proportion of oxygen) 
will withstand four times the amount of shock-producing trauma as com- 
pared with ether. When a lethal dose is administered the heart is slowed 
and death occurs by a combination of asphyxia and cardio inhibition. Con- 
trary to the general advice, Crile maintains "the heart is the key to the 
situation, the warning being too much slowing." Other authorities say that 
the heart continues to beat long after the respirations have ceased. This 
.apparent incongruity of opinions is easily explained on the ground that Crile 
in his statements refers to nitrous oxid-oxygen administration, while other 
authorities base their opinions on pure nitrous oxid. Doctor Crile is right 
in his statement, that the condition of the heart is the index of the patient's 
true state, when the combination of gases is used.* 

The Respiratory System. — Nitrous oxid is in no way irritating to the pul- 
monary apparatus, nor is there any postanesthetic complications following its 
use. The respirations under the influence of this drug are deep and more 
rapid than normal at first; as the lethal dose of the gas is approached the 
respirations become shallow and slower, until finally inhibition of respiration 
results. If the views which are at present entertained, that postoperative 
lung complications are autogenous infections, — that is to say, the specific 
organisms are latent within the patient, — and that the operative trauma, 
surgical shock, and other deleterious influences that reduce body-resistance 
are the factors which permit these latent germs to gain a foothold and pro- 
duce postoperative pulmonary complications, it can be easily understood 
from the following deductions why nitrous oxid-oxygen anesthesia does not 
cause pulmonary sequelae. 

(1) Phagocytosis is not reduced. 

(2) The patient is capable of withstanding four times as much surgical 
shock as compared with ether. 

(3) Being non-irritating to the mucous membrane of the respiratory tract, 
the local resistance is maintained in the pulmonary apparatus and any latent 
microorganisms are thus prevented from gaining a foothold. 

(4) Nitrous oxid is not a solvent of fats and therefore aspiration pneu- 
monia does not occur as with ether or chloroform, both of which latter 
dissolve the oily infectious debris that collects around the teeth and becomes 
one of the sources of postoperative pulmonary complications. 

The Digestive and Urinary Systems. — Nitrous oxid has apparently no ac- 
tion on either of these systems, so that nausea or vomiting is seldom a post- 



* See article, "Nitrous Oxid vs. Ether," by George W. Crile, M. D., Southern Medical 
Journal, January, 1910. 



296 Indications and Contraindications 

anesthetic complication ; nor does it produce changes in the structure of the 
liver as is seen in chloroform. Its effects on the structure of the kidneys 
are negative, while the urinary excretion is in no way interfered with. 

Indications and Contraindications for the Use of Nitrous Oxid-oxygen. — 
To facilitate the further consideration of this subject nitrous oyii<i-oxygen 
alone will be considered — a point which must be clearly borne in mind. If 
the extravagant statements made by some of the enthusiastic advocates of 
nitrous oxid-oxygen were to be taken seriously the conclusion would be 
reached that there were no contraindications for the use of the combined 
gases. On the other hand, if the views of the pessimistic anesthetist who 
has never given the subject of nitrous oxid-oxygen due consideration nor 
spent the required length of time to learn the proper technic for its adminis- 
tration, were conclusive, one would be forced to conclude that nitrous oxid- 
oxygen should be relegated to dentistry and minor surgery. The facts are, 
while nitrous oxid-oxygen has some deficiencies as an anesthetic, yet it 
possesses a larger scope of usefulness than any of its competitors, because 
of the following reasons. 

(1) It does not reduce phagocytosis, hence does not impair immunity, 
which claim ether does not possess. 

(2) Disintegration of the red blood-corpuscles does not occur after its 
administration. 

(3) The patient is capable of withstanding four times more operative 
trauma under nitrous oxid-oxygen than under ether before shock is 
produced. 

(4) It increases the blood-pressure, and yet this increase is practically 
under the control of the anesthetist. 

(5) Postoperative complications are exceedingly rare as compared with 
ether, besides which there is seldom any postanesthetic nausea and vomiting 
which so frequently is encountered with other drugs of this class. 

(6) It does not reduce body-temperature, which is the reverse of ether. 

(7) No deleterious effects are produced in the patient however long the 
state of anesthesia is continued. The same cannot be said of any other 
anesthetic. 

(8) The cerebral-cells being in an anoxemic condition are not as receptive 
to external stimuli as under ether. 

(9) The excretory organs of the body, the kidneys, are in no wise affected 
by its administration, hence, the economy can rid itself far easier of toxic 
elements. 



Indications and Contraindications 297 

Nitrous oxid-oxygen therefore is indicated in operations associated with 
the general infections such as septicemia, or in any of the acute infections, 
as appendicitis. In emergency operations performed for pathologic condi- 
tions, such as a leaking gall-bladder, a perforated stomach or intestine, and 
ectopic pregnancy, nitrous oxid-oxygen is by far the safest anesthetic. In 
emergencies due to violent causes such as the result of industrial accidents, 
gunshot wounds, etc., the combination of these gases is far preferable to 
ether. In operations that will consume a long period of time, in which shock 
or hemorrhage is anticipated, nitrous oxid-oxygen will conserve the patient's 
resistance far better than ether. In patients handicapped by chronic disease, 
with the usual degenerative blood-changes, nitrous oxid-oxygen should be 
used. In valvular disease of the heart if compensation is restored nitrous 
oxid-oxygen may be employed, but if degenerative changes have occurred in 
the heart muscle, or dilatation with its accompanying edema is present, 
nitrous oxid-oxygen is not indicated, nor do I consider any other anesthetic 
proper, unless in extreme necessity. In operations associated with sclerotic 
arteries and high blood-pressure, but yet with no loss of cardiac "compensa- 
tion, I consider nitrous oxid-oxygen at least as safe as ether, if administered 
by a skilled anesthetist, because the increased blood-pressure produced by 
ether cannot be regulated, while with nitrous oxid-oxygen the greater the 
percentage of oxygen combined with the anesthetic, the less will be the 
increased vascular tension; besides which, associated with sclerotic arteries 
is commonly found chronic interstitial nephritis, — Bright's disease, — a 
condition which certainly is not improved by the administration of ether. 
Likewise in operations on any portion of the urinary tract nitrous oxid- 
oxygen is well indicated. In operations on the brain nitrous oxid-oxygen 
has always been considered dangerous, because of the increased intracranial 
pressure it produces. The amount of intracranial pressure can be regulated 
at the will of the anesthetist by the amount of oxygen combined with the 
nitrous oxid. The larger the per cent, of oxygen the less will be the intra- 
cranial pressure and vice versa. I have in my own practice caused the brain 
to protrude at least one quarter of an inch through the opening in the skull, 
by having the anesthetist administer practically pure nitrous oxid, and then 
by combining 15 per cent, of oxygen with the anesthetic, immediately pro- 
duced a contraction of the brain to the extent that the organ appeared too 
small for the cranial vault. The hues of color in the superficial blood- 
vessels of the cortex varied from the darkest to the brightest red according 
to the percentage of oxygen. The caliber of the vessels was increased to an 
enormous extent when practically pure nitrous oxid was given, but con- 
tracted instantly when a large amount of oxygen was combined with the 



298 Indications and Contraindications 

anesthetic. Intracranial pressure can be regulated by the expert anesthetist. 
In operations on the thorax nitrous oxid-oxygen can be safely employed, and 
especially is it indicated where the surgeon desires the patient to be in the 
sitting posture. In operations associated with acute or chronic bronchitis 
nitrous oxid-oxygen is certainly preferable to ether, because it produces no 
irritating effects on the pulmonary passages. I do not believe it is contra- 
indicated, as some authors state, in operations associated with pulmonary 
tuberculosis because of the fear of producing hemorrhages. The adminis- 
tration of oxygen in the proper proportions will obviate any danger from 
this source by preventing an excessive increase in blood-pressure. Further- 
more nitrous oxid-oxygen has been employed in the presence of pneumonia 
without producing any harmful effects. In operations on the thyroid gland 
nitrous oxid-oxygen is used with marked success. Not only are its bene- 
ficial effects manifested during the operation, but the postoperative neuras- 
thenic condition is by no means as marked as when ether is used. Nitrous 
oxid-oxygen anesthesia is generally inadequate to produce a sufficient 
amount of relaxation of the abdominal wall in celiotomies occurring in 
highly developed muscular patients to permit complete freedom of operative 
measures ; under these conditions a few drops of ether are mixed with the 
nitrous oxid-oxygen gases to ''soften'' the rigidity of the muscular structure. 
It will be a surprise to the uninitiated to witness the immediate relaxation 
which occurs, also the small amount of ether required (generally not more 
than ten or fifteen drops), and the duration of the relaxation. 

I prefer ether or chloroform to nitrous oxid-oxygen when operating on 
young children, because the pre-anesthetic alkaloidal narcotics which should 
be employed with the combined gases are exceedingly dangerous to this class 
of patients in any dose, and if dispensed with the excessive struggling of the 
child causes too rapid an anoxemic condition to develop,— at least this has 
been my experience. 

I prefer chloroform when operating on the mouth, throat, and nose, 
because air cannot be entirely excluded and prevents a tranquil anesthesia if 
nitrous oxid-oxygen is employed. A surgeon has no right to prejudge the 
period necessary for a tonsilectomy because an unlooked for hemorrhage 
may occur, which complication is better combated in this class of cases when 
the patient is entirely in repose. My preference is for other anesthetic agents 
when operating on the rectum. 

When there is a marked reduction in the hemoglobin index, the employ- 
ment of any anesthetic is dangerous. While nitrous oxid does not produce 
anemia, nor any permanent changes in the blood, I would consider this gas 



Nitrous Oxid-oxygen — Administration 299 

as inappropriate as any other anesthetic when the hemoglobin index is very 
low, because the great deficiency of hemoglobin in such subjects would prac- 
tically permit a complete displacement of all oxygen in the presence of 
nitrous oxid-oxygen, and a true asphyxial state would ensue. On the other 
hand, if a sufficient amount of oxygen were employed to offset this total 
displacement, I doubt if sufficient anesthetic effects would be obtained. This 
deduction is made purely on theoretical grounds, and is simply offered as a 
suggestion. I have, however, by transfusion previous to operative measures 
raised the hemoglobin index from 18 to 35 per cent, and red blood-cells 
from 2,100,000 to 3,700,000 in a patient exsanguinated from uterine fibroids, 
and then administered nitrous oxid-oxygen with the most perfect results. I 
am satisfied that no anesthetic could have been given unless transfusion had 
first been utilized, and I am also convinced that no anesthetic would have 
maintained the stability in the blood as did this combination of gases. The 
results of the examination of the blood after operative interference were 
practically the same as before such measures were instituted. One of the 
greatest contraindications for the use of nitrous oxid-oxygen anesthesia is 
an incompetent anesthetist. Given such an individual, ether is the safer 
anesthetic. 

Administration of Nitrous Oxid-oxygen.— -There is no anesthetic which 
requires more special training in its administration than nitrous oxid-oxygen. 
The anesthetist must not only be dexterous, but keen in observing and 
analyzing the different symptoms and stages of anesthesia through which 
the patient passes. So rapid is its action that the subject can pass from com- 
plete surgical anesthesia into the full possession of all the faculties in a 
period of time that may be counted in seconds, so that you can appreciate 
what skill is required to maintain a tranquil anesthesia. In fact I am fully 
convinced that the unfavorable opinions concerning the scope of usefulness 
of these combined gases emanate from anesthetists unqualified in the admin- 
istration of nitrous oxid-oxygen. Because a man is a skilled ether or chloro- 
form anesthetist does not signify that he is qualified to administer nitrous 
oxid-oxygen. Few anesthetists are at the present time qualified to admin- 
ister the combined gases, and because of this fact they become pessimistic on 
the subject and attempt to influence the surgeon against the adoption of this 
form of anesthetic. This I have noted in several hospitals which I have 
visited. The time will come when the anesthetist will be required to be just 
as skillful and efficient in the administration of nitrous oxid-oxygen as in the. 
other anesthetics. 



300 



Nitrous Oxid-oxygen Anesthetic Slip 



The following nitrous oxid-oxygen chart is an easily kept and practical 
form and should be compiled during the administration of the anesthetic: 



Nitrous Oxid-oxygen Anesthetic Slip. — 

Name of patient , 

Room number , 

Pulse Respiration Blood-pressure, 

Anesthetic started , 

Initial per cent, of nitrous oxid , 

Initial per cent, of oxygen 

Anesthetic completed 

Operation started 





TIME 


PULSE 


RESP. 


BLD. PRES. 


PER CENT. 
NIT. OXID. 


PER CENT. 
OXYGEN* 























































































Anesthetic ended 

Operation ended 

Amount of nitrous oxid used (estimated) . . . 

Amount of oxygen used (estimated) 

Hypodermatic medication used 

Packing or drainage used Where 

Character of operation 



Anesthetist 
Date 



*Records of pulse, respiration, and per cent, of the combined gases should be made 
every five minutes. If the operation be a very hazardous one the blood-pressure should 
also be noted. 



Preliminary Steps — Apparatus 301 

Preliminary Steps. — 

The place of administration — operating-room.* 

Choice of location — operating-table. 

Posture — flat recumbent, unless a special position is desired. 

(1) Observe if the patient is sufficiently covered. 

(2) Ascertain if false teeth have been removed, or if any foreign body is 
in the mouth. 

(3) Instruct the patient to breathe naturally. 

(4) After a few seconds' inhalation, have the hands of the patient secured 
in an appropriate manner by an attendant. 

Several of the preliminary steps which are utilized when ether and chloro- 
form are administered are omitted, for instance, the cocainizing of the nares 
and pharynx is not necessary because nitrous oxid is not an irritant, and for 
the same reason the face demulcent and the artificial protection for the eyes 
are dispensed with. 

The Apparatus. — A special apparatus with the following requirements is 
necessary for the administration of nitrous oxid-oxygen. (See illustra- 
tion LX.) 

(1) A continuous and even flow of the gas and oxygen under a posi- 
tive and known pressure, this pressure being regulated at the will of the 
anesthetist. 

There are two methods employed to maintain a constant and even 
pressure. 

First, attach a large high-pressure cylinder (preferably 3,500 gallon 
capacity) by means of suitable hose to the nitrous oxid apparatus. Reduce 
the output of the high-pressure cylinder to about 20 pounds by means of the 
pressure-regulating valve with which it is equipped. 

The valve on the apparatus which permits the flow of the gas into the 
rubber bag further reduces the pressure, and finally the valve attached to 
the inhaler delivers it to the patient at one- to three-ounce pressure, which 
can be adjusted at the will of the anesthetist. The use of cylinders of 100- 
gallon capacity should not be used in hospitals ; the small valves with which 
these are equipped and the pressure exercised by the gas when released pro- 
duces the frost plug which has already been spoken of, and prevents a 
continuous and even flow of the gas. 



* The time consumed in transferring the patient from the anesthetizing-room to the 
operating-room as in other anesthetics would be sufficient for the patient to recover from 
the anesthetic, and would necessitate beginning the administration over again. 




Illustration LX 
A Teter Apparatus for the Administration of Nitrous Oxid-oxygen 



(302) 



Nitrous Oxid-oxygen Inhaler 303 

Second, a plant installed in the hospital for the manufacture of nitrous 
oxid. The gas is pumped from the gasometer and compressed (not liquified) 
in large storage tanks holding from 800 to 3,500 gallons. The required 
pressure is maintained in the pipes leading to the operating-room by regulat- 
ing valves. When this plan is adopted the cost to the institution is reduced 
to the minimum, and the administration of the anesthetic is simplified, 
because of the constant and even pressure that is obtained. 

(2) A mechanical device for accurately increasing or diminishing the 
per cent, of either gas. 

(3) A mixing chamber. 

(4) Some means of warming the combined gases (90° to 94°F. when 
inhaled). By this means several advantages are gained, viz. — 

(a) A more thorough and tranquil anesthesia is produced. 

(b) The pulmonary passages are protected from the refrigerant action 

of the cold nitrous oxid. 

(c) Expansion of gas occurs before inhalation, and immediate absorp- 

tion takes place after being inhaled. 

(5) An ether reservoir which is so constructed as to permit a definite 
admixture of this drug with the combined gases when necessary, or if ether 
is to be given in sequence to nitrous oxid-oxygen the construction of the 
apparatus should permit of the elimination (or shutting off) of the nitrous 
oxid-oxygen entirely, and the administration of a definite amount of 
warm ether with atmospheric air alone, or in combination with oxygen. 

(6) An inhaler consisting of a celluloid cone to which is attached a. pneu- 
matic rubber ring which permits of an accurate and easy adjustment to, the 
contour of the face. The celluloid being transparent enables the anesthetist 
to observe the color of the patient's face and lips, and if retching ensues to 
note if any vomitus has been expelled without raising the cone. This is 
important because if air is admitted a readjustment of the percentages of 
gases will be necessary. The inhaler is also equipped with expiratory and 
pressure valves. It is this latter valve which regulates the final pressure 
before inhalation. The inhaler is attached to the apparatus by means of a 
high-pressure rubber hose. (See illustration LXI.) 

A nasal inhaler constructed similarly to the above is employed in opera- 
tions on the mouth and throat. 

(7) A rebreathing attachment for those anesthetists who desire to con- 
serve the supply of gas. I am fully convinced, however, that rebreathing is 
not scientific and is based on false premises. If economy is the only reason 



304 Nitrous Oxid-oxygen — Inhalation 

for the employment of rebreathing, which apparently is the argument put 
forth, the profession should think well before adopting a plan of commer- 
cialism which may be deleterious to the patient. 

In my opinion the Teter apparatus embodies all these principles ; it is the 
apparatus used in my clinic* But after all it is not the kind of apparatus 
alone that is necessary, it is the dexterity with which the apparatus is 
manipulated, and this dexterity depends on intelligence combined with care- 
ful study of the physiologic action of nitrous oxid-oxygen. 




Illustration LXI 
Nitrous Oxid-oxygen Face Inhaler 

The Inhalation. — 

(1) Inspect the nitrous oxid-oxygen apparatus and ascertain if it is in 
working order and whether an ample supply of both gases is on hand. Regu- 
late the pressure valves. Note the odor of the gas before administration. 
This appears to be compulsory inasmuch as deaths have been reported which 
undoubtedly were due to the fact that nitric-oxid was being administered and 
not nitrous-oxid. Nitric-oxid has an odor peculiar to itself. 

(2) Place the inhaler over the mouth and nose of the patient, carefully 
noting that no air space remains between the pneumatic ring and the face, as 
ingress of air will defeat the purpose to be attained. 

(3) Open the nitrous oxid valve sufficiently to partially inflate the rubber 
bag connected with this gas and adjust it to a point that will keep the bag 
partially full. 

(4) Open the valve connected with the oxygen cylinder and inflate the 
rubber bag connected with this gas and keep it inflated throughout the 
operation. 



* I am indebted to Dr. C. K. Teter, Cleveland, Ohio, for many of the suggestions 
offered. 



Signs of Surgical Anesthesia 305 

(5) Permit the patient for the first few seconds to inhale either pure 
nitrous oxid until a slight cyanosis appears, or nitrous oxid combined with a 
very small amount of oxygen (3 per cent.). 

(6) Observe the respirations by watching the respiratory action of the 
thorax and maintain a rhythmical action of the expirations. By this is 
inferred, each expiration should be of the same quality. 

(7) Note the rate and character of the pulse, which at first will be faster 
than normal, yet possessing increased tension, but gradually approaching the 
normal. To facilitate the counting of the pulse utilize the facial artery as it 
passes under the angle of the jaw, the palpating hand supporting the head 
as has been described under "Ether" and "Chloroform," bearing in mind that 
the character of the pulse is the indication as to the true condition of the 
patient, — too much slowing of the heart's action means excessive nitrous 
oxid dosage. 

(8) Carefully note the color of the face. While cyanosis is present dur- 
ing the first few seconds in the administration of pure nitrous oxid, after 
the proper admixture of oxygen with this gas this should disappear and 
remain absent. 

(9) After surgical anesthesia has been developed, gradually reduce the 
amount of nitrous oxid and proportionately increase the amount of oxygen, 
so that possibly 90 per cent, of nitrous oxid is being administered and 10 
per cent, of oxygen. There can be no set rule governing the amount of these 
gases, but a constant stream of oxygen must always be present. There is no 
step in anesthesia that requires more dexterity and a greater nicety of adjust- 
ment than the variations in the percentages of these two gases for different 
individuals. After the adjustment has been obtained, however, there is 
probably no anesthetic with which the anesthetist can work with greater 
facility. 

(10) Do not permit the final preparation of the field of operation to be 
begun until the patient is completely anesthetized. This is a point which 
cannot be too strongly insisted on, — disturbing the patient before this stage 
is reached frequently prevents the development of a tranquil anesthesia. 

(11) If the combined gases have been given in correct proportions and 
the patient not suddenly asphyxiated, anesthesia will develop in from two 
to three minutes. 

Signs of Normal Surgical Anesthesia. — The respirations are regular and 
deep, not shallow and slow, and never stertorous. The arm falls helplessly 
to the side if raised, but muscular relaxation possibly is not as complete as 
under ether and chloroform. Conjunctival reflex is absent. 



306 Nitrous Oxid-oxygen Accidents 

Untoward Conditions. — Should asphyxial symptoms develop during the 
first few seconds of the administration of pure nitrous oxid, and the admix- 
ture of a small amount of oxygen restores the patient, only to have similar 
symptoms return when nitrous oxid is again administered, it is far better to 
reduce the amount of nitrous oxid to a minimum and add a few drops of 
ether in combination with a small amount of oxygen, then gradually increase 
the per cent, of nitrous oxid-oxygen, at the same time proportionately de- 
crease the ether until entirely dispensed with. In this way the respiratory 
center is not suddenly suspended by lack of oxygen, but gradually led up to 
the desired point when gas-oxygen may be continued. It is under these con- 
ditions that the unskilled anesthetist begins a battle which sooner or later 
exhausts the patient, and gives rise to unfavorable comment. 

If during the administration of the anesthetic the respirations become 
shallow and slow, and the anesthetist finds that by increasing the oxygen the 
patient has a tendency to come from under the influence of nitrous oxid, the 
admixture of 10 or 15 drops of ether with the combined gases will at once 
accelerate and deepen the respiratory movements because of its known stim- 
ulating action on this system. 

It sometimes happens, as in other anesthetics, that sudden cessation of 
respiration is due to the tongue falling backward and obstructing the larynx ; 
this should be borne in mind and provisions made for relieving the ob- 
struction by pulling the tongue forward. 

The muscular structures are not as completely relaxed under nitrous oxid- 
oxygen as under ether or chloroform, but if the patient has been properly 
prepared by the administration of the pre-anesthetic alkaloidal narcotics, 
such as morphin and hyoscin, this deficiency is practically overcome. In 
celiotomies performed on highly developed muscular subjects a few drops 
of ether will "soften" abdominal muscles and permit as wide a latitude of 
operative manipulations as under any other anesthetic; it will be a surprise 
to the uninitiated to note the small amount of ether necessary for this pur- 
pose (not over 15 or 20 drops), and the duration of the relaxation.* 

Accidents Occurring During Administration of Nitrous Oxid-oxygen. — 
If during the administration of gas-oxygen the patient develops profound 
cyanosis, or the heart's action becomes very slow, nitrous oxid is imme- 
diately suspended and pure oxygen administered, when the patient will at 
once return to a normal condition. In fact oxygen is the key, indirectly or 
directly, to all accidents occurring during the administration of nitrous oxid. 
// the respirations cease entirely, artificial respiration or Laborde's method 



* In my last 200 operations under nitrous oxid-oxygen as administered by Dr. R. A. 
Rice of Grant Hospital, ether has been entirely dispensed with and the most perfect 
results have been obtained. 



Accidents During Administration 307 

of rhythmical movements of the tongue in addition to the administration of 
oxygen, should be instituted. (See section "Artificial Respiration" of this 
lecture.) // the heart is suddenly checked in over dilation, cardiac massage 
as has been described when speaking of "Chloroform," should be em- 
ployed. While I have never witnessed such an accident, I would not 
consider it advisable to place the patient in the Trendelenberg position, 
inasmuch as the blood gravitating to the already dilated heart would pro- 
duce further distention of that organ. 

BIBLIOGRAPHY. 
Keen's Surgery — Hob art A. Hare, M. D. 

American Practice of Surgery — Freeman Allen, M. D., and F. E. Gar- 
land, M. D. 

Anesthetics, Their Uses and Administration — D. W. Buxton, M. D., B. S. 

Artificial Anesthesia — Lawrence Turnbull, M. D., Ph. G. 

A Practical Guide to the Administration of Anesthetics — R. J. Probyn- 

WlLLIAMS, M. D. 

Nitrous Oxid vs. Ether — Geo. W. Crile, M. D. 

The Choice of the Anesthetic — Arthur D. Bevan, M. D. 

C. K. Teter, D. D. S., Cleveland, O. 



PHYSICIANS, SCIENTISTS, AND OTHERS QUOTED 



Doctors 

Allen, Freeman 
Andrews, Edmund 
Bartlett, Willard 
Bevan, Arthur D. 
Boyd, Francis B. 
Buxton, D. W. 
Coons, J. J. 
Crile, Geo. W. 
DaCosta, J. Chalmers 
Darnell, Carl R. 
Dunham, John D. 

ElSENDRATH, DANIEL N. 

Eve, Duncan 
Frazier, Chas. Harrison 
Garland, F. E. 
Halsted, W. S. 
Haubold, H. A. 
Hare, Hobart A. 
Hartley, Frank 
Heineck, A. P. 
Hill, Leonard 
Holmes, Oliver Wendell 
Kelly, Howard A. 
Lexer, Ehrich 
Lister, Sir Joseph 



Doctors 

Long, Crawford W. 
Ludwig, E. C. 
Matas, Rudolph 
Moore, Jas. E. 
Morse, N. C. 
Morton, Wm. T. G. 
Mumford, Jas. G. 
Murphy, John B. 
Meyer and Schmieden 
Ohlmacher, A. P. 

PlLCHER, P. M. 

Probyn-Williams, R. J. 
Rice, R. A. 
Robertson, Jean 
Robinson, Byron 
Simpson, Sir James Young 
Taite, Lawson 
Tilton, Benjamin T. 
Turnbull, Lawrence 
Warren, J. C. 
Wells, Horace 
Whiting, A. D. 
Williams, E. H. 
Wright, A. E. 
Yates, John L. 



Allridge, Lizzie 
Barton, Clara 
Colton, G. Q. 
Davey, Sir Humphrey 
Dunant, Henri 
Fenzel, Harriet 
Franklin. Benjamin 



Guthrie, Samuel 
Haskins, Frederick 
Jackson, C. T. 
Mesmer, Friedrich Anton 
Nightingale, Florence 
Pasteur, Louis 
Priestly, Joseph 



309 



INDEX 



Abdominal Binder, 55 

outfit, 42 

sponges, 40 

counting of, 41, 190, 192 
Abrasions, 134 
Acid, Boracic, 24 

Carbolic, 20 

Oxalic, 22 
Adhesive Plaster, 58 
Air, superheated, 15 
Alkaloidal Medication (hypodermatic), 

reasons for, 87 

technic of, 86 

narcotics in pre-operative prepara- 
tion, 87 
Albumen, egg, 214 

method of preparing, 83 
Alexins, 11 
American Association for the Relief of 

Miseries on the Battlefield, 5 
American Red Cross, 5 
Anaerobic, 245 
Anastomosis, 102 
Andrews, Dr. Edmund, 263 
Anesthetics, 260 

administration of local, 269 

alkaloidal narcotics in, 267 

chloroform first used as, 266 

dose of alkaloidal narcotics with, 268 

ether first used as, 264 

field of application of, 266 

history of, 262 

introduction to, 260 

mixed, 266 

mixtures, 270 

modifications in preparation of pa- 
tient for, 273 

nitrous oxid first used as, 264 

preparation of patient for, 271 

sequence of, 270 

slips, chloroform and ether, 279 
nitrous oxid-oxygen, 300 

statistics of, 275 



Anesthetics — continued 

strength of solution of local, 270 

transfusion as preparatory step in, 
273 

use of local with general, 268 
Anesthetist, 275 

expert vs. amateur, 261 
Anesthetizing-room, 274 
Ankylosis, 165 
Antiseptic, definition of, 19 

surgery, definition of, 19 
Antiseptics, 19 

abuse of, 24 

list of, 19 

mechanical, 25 
Apparatus, suction, 16 
Argyrol, 22 
Aristol, 24 

Arteries, function of (see Blood-ves- 
sels), 102 

terminal, 103 
Articulation or Joint, 162 

tissues entering into, 162 
Artificial Heat, 207 

respiration, Howard's, 284 
Laborde's, 284 
Sylvester's, 284 
Asepsis, chain of, 32 

illustrations of breaks in, 33 
Aseptic Surgery, definition of, 32 
Attire of Patient for Operating-room, 85 



Bacteria, avenues of entrance of, 9 
exit from economy, 10 
invasion of economy by, 9 
the more common, 8 

Bandages, 54 

abdominal binder, 55 
best material for roller, 54 
elastic, 15 
figure-of-eight, 55 



311 



312 



Index 



Bandages — continued 

many-tailed, 55 

parts of roller, 54 

plaster-of-Paris, 57 

rules for applying, 57 

reverse turn in roller, 54 

roller, 54 

scultetus, 55 

silicate-of-soda, 58 

rules for applying, 58 

"T", 57 
Barton, Clara, 5 
Basin Sterilizer, 61 

Bathtub and Basins as Carriers of In- 
fection, 75 
Bed-sore, 150 
Bib-apron, 39 
Bichlorid of Mercury, 19 
Biniodid of Mercury, 20 
Bird's Nest Protective, 158 
Blank Form for Filing History-record, 
70 

history-record, 68 
Blankets, 48 
Blood, absolute count, 12 

amount of in body, 127 

differential count, 12 

physiology of, 11, 126 

relative count, 12 
Blood-counting, 11 

table of, 12 

value of, 12 
Blood-pressure, 119 

estimation of, 106 

factors concerned in, 119 

normal height of, 119 
Blood-vessels, 102 

changes incident to ligation of, 104 

division of, 102 

functions of endothelial lining of, 
103 

histology of, 103 

process of repair of, 103 
Body-resistance, 11 
Boracic Acid, 24 
Bowel, acute obstruction of, 241 

causes of, 241 

nurse's duties in, 242 

symptoms of, 241 

treatment of, 241 
Boyd, Dr. Francis B., 217 



Bradford Frame, 160 

Buck's Extension Apparatus, 156 

application of, 156 
Burns and Scalds, 168 
Burns, causes of death from, 171 
classification of, 168 
first degree, 168 
second degree, 169 
third degree, 170 
constitutional treatment of, 169, 170, 
171 

first degree, 169 
second degree, 170 
third degree, 171 
electrical, 172 

local treatment of, 168, 169, 170 
first degree, 168 
second degree, 169 
third degree, 170 
nurse's duties in, 171 
symptoms and course of, 168, 169, 
170 

first degree, 168 
second degree, 169 
third degree, 170 
Buxton, Dr. D. W., 294 



Callus, central or medullary, 148 

external or unsheathing, 148 

permanent, 149 

temporary, 148 
Caps, 38 
Carbolic Acid, 20 

antidote for, 20 
Carbonate of Soda, 22 
Cartilage, 162 

Catgut (see Sutures and Ligatures), 49 
Cathartics, 85, 219 

after operations, 219 

before operations, 85 
Catheterization, 80 

after operations, 217 

before operations, 80, 87 

dangers of, 218 

technic of, 80, 218 
Celiotomy Sheet, 48, 189 
Charts, Clinical, 63 
Chilblains, 174 



Index 



313 



Chlorid of Lime, 22 
Chloroform, 276 

accidents occurring under, 282 
administration of, 279 

preliminary steps in, 280 
anesthetic slip, 279 
container, 281 

deaths occurring under, 277 
discovery of, 263 
effects of on the blood, 277 
cerebro-spinal system, 276 
heart and circulatory system, 

276 
kidneys, 278 
liver, 278 

respiratory system, 276 
skin, 278 
indications and contraindications 

for, 278 
inhalation of, 281 
inhalers, 281 
physical and chemical properties of, 

276 
signs of normal surgical anesthesia 

under, 282 
untoward conditions occurring un- 
der, 282 
Cicatrix (or Scar Tissue), 104, 135 
Cigarette Drains, 53 
Circulation, collateral, 103 
Cleansing, mechanical, 72 
Clinical Charts, 63 
keeping of, 64 
Clinical Surgery, modern, 6 
Clonic Convulsions, 246 
Colton, G. Q., 263 
Complications, postoperative, 224 
Contusions, 134 
Convulsions, clonic, 246 
Coons, Dr. J. J., 12 
Cordus, Valerius, 263 
Corrosive Sublimate, 19 
Cotton Gauze, 41 
Counting of Abdominal Sponges, 41, 190, 

192 
Cradle, 159 
Creolin, 20 
Crile, Dr. Geo. W„ 105, 119, 267, 268, 

273, 295 
Cunningham Elevator, 196 



Cupping-glasses, 15 

method of applying, 16 
Current, peritoneal, 98 
Cystitis, 218 



DaCosta, Dr. J. C, 54 
Davey, Humphrey, 263 
Decubitus, 150 
causes of, 150 
treatment of, 150 
Deodorant, 19 
Diet List, 83, 213 

after operations, 213 
before operations, 83 
Disinfectants, 19 

list of, 19 
Dislocations (see Sprains), 162 
after-treatment of, 167 
anatomical divisions of, 163 
causes of, 163 
changes occurring in joint after, 

165 
classification of, 163 
complete, 163 
complicated, 163 
compound, 163 
congenital, 163 
incomplete, 163 
old or ancient, 163 
simple, 163 
definition of, 163 
differentiation of, 165 
signs of, 164 

abnormal position of articular 

end of bone, 164 
ecchymosis in, 164 
loss of contour in, 164 
pain in, 164 

preternatural immobility in, 164 
radiograph in, 164 
swelling in, 164 
treatment of, 165 
Donee, 105 
Donor, 105 

Dorsal Recumbent Position, 90 
method of obtaining, 90 
use of, 90 
Dorsosacral Position, 92 

method of obtaining, 92 
use of, 92 



314 



Index 



Drain, 53 

cigarette, 53 

in infected wounds, 142 

Mikulicz, 53 

rubber tube, 53 
Dressings (see Gauze), 41 

abdominal outfit, 42 

change of, 140 

cotton-gauze, 41 

dry, in infected wounds, 143 

gutta-percha tissue, 44 

iodoform gauze, 42 

moist, in infected wounds, 143 

oiled silk, 34 

plain sterile gauze, 41 

rubber dam, 44 

sublimate gauze, 42 

tape or gauze packing, 43 

ward service outfit, 49 

wound after operation, 220 
Dunant, Henri, 4 
Dunham, Dr. John D., 217 
Dusting Powders, 24 

objections to, 24 
Dyspnea, 247 



Egg Albumen, 214 

method of preparing, 83 
Elastic Bandage, 15 

rules for applying, 15 
Electrical Burns, 172 
Elevator, Cunningham, 196 

Lilienthal, 194 
Embolism, 235 

causes of, 235 

classification of, 235 

aseptic or simple, 235 
septic or infectious, 235 

symptoms of, 235 

treatment of, 236 
Embolus, 235 

causes of, 235 
Emergencies, complications of, 202 
Emergency Operating-room, 199 

patient, 202 
Endosteum, 148 
Enemata, 225 

administration of nutrient, 217 

formulae for nutrient, 216 



Enemata — continued 

in postoperative treatment, 225 
in pre-operative preparation, 85 
nutrient, 215 
Enteroclysis, 110 
Equipment of Surgeon's and Nurses' 

Dressing-rooms, 184 
Erysipelas, 242 
causes of, 243 
nurse's duties in, 244 
symptoms of, 243 
treatment of, 244 
Eserin Salicylate, 226 
Ether, 285 

accidents occurring under, 293 

anesthetic slip, 279 

container, 288 

discovery of, 263 

effects of on the blood, 286 

cerebro-spinal nervous system, 

286 
eye, 287 

heart and circulatory system, 285 
kidneys, 287 
respiratory system, 286 
skin, 287 
indications and contraindications 

for, 287 
inhalation by open method, 288 

semiopen method, 290 
inhalers, 288, 290 
physical and chemical properties of, 

285 
signs of normal surgical anesthesia 

under, 292 
untoward conditions occurring un- 
der, 292 
Evaporating Lotions, 21 

formula for, 21 
Extension Apparatus, Buck's, 156 



Face Masks, 39 

Face, pre-operative preparation of, 82 

Feet, pre-operative preparation of, 83 

Fenzel, Harriet, 216 

Fibrin, 103 

Figure-of-eight Bandage, 55 

First Intention, healing by, 134 



Index 



315 



Fistula, fecal, 242 
causes of, 242 
symptoms of, 242 
treatment of, 242 
Flat Recumbent Position, preparation 

of, 206 
Formaldehyd, 21 
Formalin, 21 
Fowler Position, 96 

methods of obtaining, 96 
philosophy of, 98 
preparation of, 206 
Fractures, 145 

after-treatment of, 159 
ambulatory treatment of, 158 
anesthesia in, 153 
bed, 159 
box, 158 

Bradford frame in, 160 
catheterization in, 160 
causes of, 146 
classification of, 145 

complicated, 146 

comminuted, 145 

compound, 145 

green-stick, 146 

gunshot, 146 

impacted, 145 

multiple, 145 

simple, 145 
complications following, 149 
condition of circulation in, 160 
decubitus or bed-sore in, 150 
delayed union in, 150 
diet in, 160 
differentiation of, 165 
double-inclined plane for, 157 
dressings employed in, 143 
extension apparatus for, 156 
first aid in, 151 
infection in, 151 
injuries of blood-vessels in, 149 
injuries of nerves in, 149 
modifications in treatment of, 155 
nonunion in, 150 
oblique, 146 
passive motion in, 160 
pathologic, 146 
plaster-of-Paris cast for, 155 
pneumonia in, 151 
preparation of patient in, 152 



Fractures — continued 
repair of, 148 
shock in, 151 
signs of, 146 

crepitus, 147 

deformity, 147 

loss of function, 147 

preternatural mobility, 147 

radiograph, 147 
spiral, 146 
transverse, 146 
treatment of, 151 
vicious union in, 150 
Freezing and Frost-bites, 173 
classification of, 173 

general, 173 

local, 173 
degrees of local, 173 

first, 173 

second, 173 

third, 174 
nurse's duties in, 176 
symptoms and causes of, 173, 174, 
175 

general, 175 

first degree, 173 

second degree, 174 

third degree, 174 
treatment of, 173, 174, 175 

general, 175 

first degree, 173 

second degree, 174 

third degree, 174 
Franklin, Benjamin, 262 
Frazier, Dr. Charles H., 245 
Furniture of Operating-room, 178 



Gastro-intestinal Rest after Operations, 

212 
Gauze (see Dressings), 37 
dressings, sterile, 41 
fluffy, 41 

identification of, 37 
iodoform, 42 

method of making, 42 
medicated, 42 
iodoform, 42 
sublimate, 42 



316 



Index 



Gauze (see Dressings) — continued 
sponges, 39 

preliminary count and record 

of, 41 
varieties of, 39 
abdominal, 40 
large abdominal, 40 
small or wipe, 39 
sublimate, 42 

method of making, 42 
tape or packing, 43 
Germicides, 19 
Gloves, 45 

adjustment of, 46 
care of, 45 

three methods of sterilization of, 46 
Gowns, 37 

various styles of, 37 
Granulation Tissue, 135 
healing by, 135, 136 
Granulations, prolific, 136 
Guthrie, Samuel, 263 
Gutta-percha Tissue, 263 



Halsted, Dr. W. S., 49 

Hands, pre-operative preparation of, 83 

preparation and sterilization of sur- 
geon's, 72 

sterilization of, chemicals used in, 
74 
Hare, Dr. Hobart A., 275, 276, 285 
Harrington's Solution, 21 

formula for, 22 
Hartley, Dr. Frank, 95 
Hartley Position, 95 

method of obtaining, 95 

use of, 96 
Head, operations on, 193 

pre-operative preparation of, 80 
Head-down Position, 206 

method of obtaining, 206 

use of, 205 
Heat, artificial, 207 
Hemolysis, 105 
Hemophilia, 126 
Hemorrhage, 126 

classification of, 126 - 
arterial, 126 



Hemorrhage — continued 
capillary, 126 
concealed, 126 
primary, 126 
secondary, 126 
venous, 126 

nurse's duties in, 132 

pathology of, 127 

symptoms of, 128 

treatment of, 128 
Hill, Dr. Leonard, 273 
Hippocratic Countenance, 230 
Historical sketches, 1 
History of Patient, blank form for, 68 
History-record, 67 

compiling of, 69 

filing of, 70 
Holmes, Dr. Oliver Wendell, 262 
Horsehair, 52 
Hydrogen Dioxid, 22 
Hyperemia, artificial, 15 

classification of, 15 

means for production of, 15 
Hypodermatic Alkaloidal Medication, 86 
Hypodermoclysis, 117 

accessories necessary for, 117 

administration of a, 118 

choice of location for, 117 

disadvantages of, 117 

nurse's duties in, 118 
Hypnotics in Pre-operative Preparation, 
85 



Infected Hands, difficulty of sterilizing, 

34 
Infection, 8 

bathtub and basins, carriers of, 33, 
35, 75 

general (see septic intoxication, sep- 
ticemia, and pyemia), 8, 236 

local, 8 

manner of spreading, 10 

mixed, 9 

of operative wound, 226 

principles of, 8 

secondary, 9 

simple, 9 

ungloved hands, source of, 34 
Inflammatory Action, formation of, 14 



Index 



317 



Infusion, 106 

bottle under air pressure for, 107 

objections to, 108 
classification, 106 

hypodermoclysis, 117 
intra-abdominal, 118 
intravenous, 107 

proctoclysis or enteroclysis, 110 
general effects of, 106 
gravity reservoir for, 108 

merits of, 108 
intra-abdominal, 118 
intravenous, 107 

choice of location for, 109 
modification in, 109 
nurse's duties in, 109 
needles, 109 
outfit, 61 
rectal, 110 
subcutaneous, 117 
Inhalation of Chloroform, 281 
ether by open method, 288 
semiopen method, 290 
nitrous oxid-oxygen, 299 
Inhaler, chloroform, 280, 281 
ether, 288, 290 
nitrous oxid-oxygen, 304 
Inosculation, 102 

International Red Cross Society, 4 
Intra-abdominal Infusion, 118 
Intravenous Infusion. 107 
Instrument Sterilizer, 61 
Iodin, 20 
Iodoform, 24 
Iodoform Gauze, preparation of, 42 

Jackson, Dr. C. T., 264 
Joint or Articulation, 162 



Kangaroo Tendon, 52 
Kelly, Dr. Howard A., 214 
Kidney, operations on, 196 
Knee-chest Position, 90 

method of obtaining, 90 

use of, 91 



Letheon, 264 
Leukocytes, 11 
Leukocytosis, 11 



Leukopenia, 11 
Ligaments, 162 
Ligatures (see .Sutures), 49 

materials used in, 49 
catgut, 49 
pagenstecher, 52 
silk, 52 

quality of perfect, 49 
Lightning Stroke, 172 
Lilienthal Elevator, 194 
Lister, Sir Joseph, 6 
Lithotomy Position, 92 

method of obtaining, 92 

use of, 92 
Lithotomy Sheet, 197 
Liver, operations on, 194 
Locations, modifications of technic for 

special, 193 
Lockjaw, 245 

Long, Dr. Crawford W., 264 
Lotions, evaporating, 21 

formula for, 21 
Ludwig, Dr. E. C, 292 
Lymphatic System, 10 
Lysol, 20 



Major Surgery in Private Practice, 25Q 
Many-tailed Bandage, 55 
Matas, Dr. Rudolph, 126 
Mechanical Antiseptics, 25 

cleansing, 72 

basic principles of, 72 
Memoranda, sickroom, 63 
Menu in Postoperative Cases, 214 

pre-operative preparation, 84 
Mercury, bichlorid, 19 

biniodid, 20 
Mesmer, Friedrich Anton, 262 
Metric System, approximate equivalents 
to apothecaries' measure, 23 

method of preparing solutions by, 23 
Milk, objections to after celiotomies, 83,. 
215 

before celiotomies, 83 
Modern Clinical Surgery, birth of, 6 
Moore, Dr. Jas. E., 8 
Morphin, use of after operations, 208 
Morse, Dr. N. C, 78 



318 



Index 



Morton, Dr. Wm. T. G., 264 

Mouth, pre-operative preparation of, 81 

Murphy, Dr. John B., 110 



Narcotics, alkaloidal, in pre-operative 

preparation of patient, 87 
Natural Resistance, 11 

artificial means of assisting, 15 
Nausea and Vomiting after Operations, 

207 
Neck, operations on, 194 
Nerves, vasomotor, 103, 120 
Nightingale, Florence, 1 
Nitrous Oxid, 293 
discovery of, 263 
effects of on the blood, 293 
cerebro-spinal system, 294 
digestive system, 295 
heart and circulatory system, 

294 
respiratory system, 295 
urinary system, 295 
physical and chemical properties of, 
293 
'Nitrous Oxid-oxygen, accidents occur- 
ring under, 306 

administration of, 299 

preliminary steps in, 301 
anesthetic slip, 300 
apparatus for administration of, 301 
indications and contraindications for, 

296 
inhalation of, 304 
inhaler for, 304 
signs of normal surgical anesthesia 

under, 305 
untoward conditions occurring un- 
der, 306 
Normal Saline Solution, 59 
field of usefulness, 59 
preparation of, 59 
Nourishment and Water after Operation, 

210 
Nurse, assignment of after operation, 

204 
Nurses' and Surgeon's Dressing-rooms, 

181 
Nurses' Aprons, 39 



Nurses' Hands, sterilization of, 72 
Nursing, principles and practice of post- 
operative, 204 

surgical, 8 
Nutrient Enemata, 215 

administration of, 217 

formulae for, 216 



Ohlmacher, Dr. A. P., 18 
Oiled Silk, 44 
Operating-room, 177 

artificial illumination of, 177 
care of, 181 
equipment of, 177 

final duties of first assistant nurse, 
190 

head nurse, 188 

non-sterile nurse, 188 
furniture of, 178 
heating of, 177 

nurses' preparatory toilet for, 185 
patient's attire for, 85 
preliminary duties of first assistant 
nurse, 186 

head nurse, 187 

non-sterile nurse, 185 
technic of, 185 
water in, 177 
Operating-room, emergency, 199 

duties of first assistant nurse in, 201 

head nurse in, 201 

second assistant nurse in, 200 
equipment of, 199 
maintaining efficiency of, 200 
technic of, 200 
Operations, 191 
abdominal, 188 
artificial heat after, 207 
cathartics after, 219 
catheterization after, 217 
diet list after, 213 
dressing wound after, 220 
examination of urine after, 217 
gastro-intestinal rest after, 212 
morphin after, 208 
nausea and vomiting after, 207 
nurse assigned after, 204 
on the head, 193 



Index 



319 



Operations — continued 
kidney, 196 
liver, 194 
neck, 194 
vagina, 196 
pain after, 208 

period of confinement after, 222 
positions of patient in bed after, 204 
proctoclysis after, 212 
pulse and temperature after, 209 
removal of sutures after, 220 
respiration after, 210 
water and nourishment after, 210 
Operative Cases, classification of, 75 
Operative Wound, 226 
infection of, 226 
causes of, 226 
symptoms of, 226 
treatment of, 227 
Opisthotonos, 246 
Opsonic Index, 18 
Opsonins, 11 
Oxalic Acid, 22 
Oxygen, discovery of, 263 



Pagenstecher, 52 

Pain after Operations, 208 

Paresis, 217 

Passive Motion, 160 

Pasteur, Louis, 6 

Patient's Toilet after Operation, 221 

Periosteum, 148 

Peritoneal Current, 98, 205 

Peritoneum, 227 

functions of, 228 
Peritonitis, 228 

causes of, 228 

prophylaxis of, 230 

symptoms of, 229 

treatment of, 231 
Permanganate of Potash, 22 
Phagocytes, 11 
Phagocytic Index, 18 
Phagocytosis, 11 
Phlebitis, 232 

causes of, 233 

final results in, 233 

symptoms of, 233 

treatment of, 233 



Physiologic Saline Solution, 59 

field of usefulness, 59 

preparation of, 59 
Pitchers, sterilizer for, 61 
Plaster-of-Paris Bandage, 57 

removal of, 57 

rules for applying, 57 
Pneumatic Suit, Crile's, 123 
Pneumonia, 151, 240 

hypostatic, 151 

traumatic, 151 

treatment of, 240 
Polynuclear Neutrophiles, 12 
Position, dorsal recumbent, 90 

dorsosacral, 92 

flat recumbent, preparation of, 206 

Fowler, 96 

preparation of, 206 

Hartley, 95 

head-down, preparation of, 206 

knee-chest, 90 

lithotomy, 92 

Sims's, 89 

Trendelenberg, 92 
Positions or Postures of Patient, 88 
Postoperative Complications, 224 

nursing, principles and practice of. 
204 
Potassium Permanganate, 22 
Pre-antiseptic Age, 5 
Preparation of Field of Operation, final, 
188 

primary, 78 
Preparation of Patient for Operation, 75 

alkaloidal narcotics in, 87 

cathartics in, 85 

diet in, 83 

drinking water in, 84 

dry vs. moist protective dressings in, 
79 

enemata in, 85 

equipment of dressing car for, 77 

ether, benzin, or alcohol in, 78 

hypnotics in, 85 

menu in, 84 

modifications of special locations in, 
80 

face, 82 
feet, 83 
hands, 83 



320 



Index 



Preparation of Patient for Operation — 
continued 

head, 80 
mouth, 81 
rectum, 82 
stomach, 81 
thorax, 82 
vagina, 82 
nurse selected for, 77 
nurse's preparation for, 78 
obtaining specimen of urine in, 80 
preliminary duties in, 77 
soap poultice in, 80 
Priestly, Joseph, 263 
Primary Union, healing by, 134 
Principles and Practice of Postoperative 

Nursing, 204 
Principles of Infection, 8 
Private Practice, major surgery in, 250 
Proctoclysis, 110 

administration of a, 115 

after operations, 212 

author's outfit for, 112 

deductions drawn from physiologic 

principles in, 111 
extemporized outfit for, 114 
nurse's duties in, 116 
physiologic principles involved in, 

110 
range of application of, 116 
single-tube apparatus for, 114 
types of apparatus for, 112 
Proud Flesh or Prolific Granulations, 

136 
Ptomain, 8 

Pulse and Temperature after Opera- 
tions, 209 
Pus, 8 

constituents of, 14 
Pyemia, 239 

causes of, 239 
nurse's duties in, 240 
symptoms of, 239 
treatment of, 240 



Rectal Feeding, 215 

infusion, 110 
Rectum, pre-operative preparation of, 
82 



Red Cross, American, 5 

Red Cross Society, The International, 4 

Resistance, body, 11 

natural, 11 
Respiration after Operations, 210 
Rest in Infected Wounds, 143 
Reverse Turn in Bandage, 54 
Rice, Dr. R. A., 306 
Risus Sardonicus, 246 
Robertson, Dr. Jean, 217 
Rubber Dam, 44 
Rubber Drainage Tubes, 53 

sheets, 48 



Saline Solution, normal, 59 

Sapremia, 236 

Scalds and Burns, 168 

Scar Tissue, 104, 135 

Scultetus Bandage, 55 

Second Intention, healing by, 135 

process of repair by, 135 
Septic Intoxication, 236 

causes of, 237 

final results in, 237 

symptoms of, 237 

treatment of, 237 
Septicemia, 238 

causes of, 238 

nurse's duties in, 239 

symptoms of, 238 

treatment of, 239 
Sheet, celiotomy, 48, 189 

lithotomy, 197 
Shock, 119 

bed, 124 

compared with concealed hem- 
orrhage, 122 

causes of, 120 

Crile's theory of, 121 

nurse's duties in, 124 

symptoms of, 121 

treatment of, 122 
Sickroom Memoranda, 63 

keeping of, 64 
Silicate-of-soda Bandage, 58 

rules for applying, 58 
Silk, 52 



Index 



321 



Silkworm Gut, 52 

Simpson, Sir James Young, 266 

Sims's Position, 88 

method of obtaining, 89 

use of, 89 
Skin-grafting, 136 
Soap Poultice, 80 
Solutions, 23 

method of making by apothecaries' 
measure, 23 

metric system, 23 
Spasm, tonic, 246 
Splint-room, 154, 203 
Splints, 153 

change of, 155 

qualities of material necessary for, 
154 
Sponges, counting of, 41, 190, 192 
Sprains (see dislocations), 162 

compared with dislocations, 163 

treatment of, 166 
Sphygmomanometer, 106, 119 
Sterilization, 29, 30 

by boiling water, 30 

dry heat, 30 

fractional method, 30 

intermittent method, 30 

steam under pressure, 29 
without pressure, 30 

of hands, chemicals used, 74 
nurse's, 72 
surgeon's, 72 
Sterilizer, 61 

for basins, 61 

for instruments, 61 

for pitchers, 61 

for water, 61 
Sterilizing-room, 25 

drugs, chemicals, and accessories 
kept in, 28 

furniture of, 27 
Stomach, pre-operative preparation of, 

81 
Stupes, turpentine, 226 
Subcutaneous Infusion, 117 
Sublimate Gauze, 42 
Subluxation, 163 
Suction Apparatus, 16 

method of applying, 16 
Superheated Air, 15 

apparatus, 17 



Surgeon's and Nurses' Dressing-rooms, 
181 

suits and shoes, 38 
Surgery, definition of, 8 
Surgery in Private Practice, 250 

duties of nurse on arrival at home 

of patient in, 253 
extemporized operating-room for, 

253 
final preparation of field of opera- 
tion in, 258 
list of necessary articles for, 254 
nurse's duties day of operation in, 
256 

during operation in, 258 
immediate duties in, 250 
preparation of patient in, 256 
patient's bed in, 256 
room for, 253 
sterilization in, 255 
Surgeon's outfit for, 252 
Surgical Nursing, definition of, 8 
Surgical Shock, 119 
Sutures, 49 
catgut, 49 

Bartlett's method of steriliza- 
tion of, 50 
part of intestine used in, 49 
sterilization of, 50 
varieties of, 50 
horsehair, 52 
kangaroo tendon, 52 
materials used in, 49 
necessary equipment for removal 

of, 221 
pagenstecher, 52 
qualities of perfect, 49 
removal of after operations, 220 
silk, 52 

silkworm gut, 52 
technic of removal, 221 
wire, 52 
Synovial Membrane, 162 



"T" Bandage, 57 
Taite, Dr. Lawson, 
Talcum Powder, 48 



322 



Index 



Tape or Gauze Packing, 43 

preparation of, 43 
Technic of Operating-room, 185 
Tendons, 162 
Terminal Arteries, 103 
Tetanus, 245 

chronic, 247 

diet in, 249 

mode of entrance of bacilli, 245 

prognosis in, 247 

symptoms of, 246 

toxin dissemination in, 246 

treatment of, 247 
Teter Apparatus, 302 
Third Intention, healing by, 136 
Thorax, pre-operative preparation of, 82 
Thrombophlebitis, 232 
Thrombosis, 234 

causes of, 234 

classification of, 234 

final results in, 234 

symptoms of, 234 

treatment of, 235 
Thrombus, 103, 234 

Toilet, nurses' preliminary, for operat- 
ing-room, 185 
Tonic Spasm, 246 
Towels, 48 
Toxemia, 8, 236 
Toxin, 8 
Transfusion, 105 

accessories necessary for, 106 

objects of, 105 
Trendelenberg Position, 92 

disadvantages of, 94 

method of obtaining, 93 

use of, 94 
Trismus, 246 
Turbans, 38 
Turpentine Stupes, 226 
Tympanites, 234 

causes of, 225 

nurse's duties in, 226 

symptoms of, 225 

treatment of, 225 



Urine, rules for obtaining specimen of, 
80, 87 

examination of after operations, 217 



Vaccines, 17 

autogenous, 17 

dose and frequency of, 18 
Vacuum-cups, 15 
Vagina, operations on, 196 

pre-operative preparation of, 82 
Vasa Vasorum, 103 
Vasoconstrictors, 120 
Vasodilators, 120 
Vasomotor Nerves, 103, 120 

center of, 120 
Veins, function of, 102 

valves of, 102 
Vena Cava, inferior, 102 

superior, 102 



Ward Service, 61 

aseptic cupboard, 61 
stand, 61 
table, 61 
Warren, Dr. J. C, 264 
Water and Nourishment, 84, 210 
after operations, 210 
before operations, 84 
Water Sterilizer, 61 
Wells, Dr. Horace, 264 
Whiting, Dr. A. D., 50 
Williams, Dr. E. H., 261 
Wire, varieties of, 52 
Wounds, 133 
aseptic, 139 

change of dressings in, 140 
complications of, 140 
equipment for dressings in, 140 
removal of stitches in, 141 
technic for change of dressings, 
140 

removal of stitches, 141 
treatment of, 139 
classification of, 133 
contused, 133 
gunshot, 134 
inoised, 133 
lacerated, 133 
open surgical, 134 
punctured or stab, 133 
cleanliness in, 138 
contused, 133 



Index 



323 



Wounds — continued 

ecchymosis, produced by, 138 

general consideration of, 137 

gunshot, 134 

healing by first intention, 134 
second intention, 135 
third intention, 136 

hemorrhage in, 137 

incised, 133 

infected, 134, 141 

change of dry dressings in, 143 

moist dressings in, 143 
drainage in, 142 
dry dressings in, 143 
hyperemic treatment of, 144 
moist dressings in, 143 
principles involved in treatment 

of, 142 
rest in, 143 



Wounds — continued 

treatment of, 141 

lacerated, 133 

nurse's duties for first twenty-four 
hours, 139 

open surgical, 134 

pain of, 138 

poisoned, 134 

prolific granulation in, 136 

punctured or stab, 133 

recapitulation of healing process, 136 

repair of, 134 

rest in, 138 

scar tissue in, 136 

skin grafting in, 136 

stab, 133 
Wright's Dictum, 18 

hypothesis, 17 
Wright, Dr. A. E., 17 



JAN 8 1913 



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